Informed Consent for Physical Therapy and Physiotherapy Services

Procedure Name

Form Sections

Section 1info grid

Physical Therapy Practice Name

Attending Physical Therapist

Patient Full Legal Name

Date of Birth

Patient ID / Chart Number

Primary Treatment Area

Section 2text block

Section 3list block

Section 4text block

Section 5list block

Section 6text block

Section 7text block

Section 8text block

Section 9text block

Section 10signature block

Patient / Authorized Representative Signature

Attending Physical Therapist Signature

Informed Consent for Physical Therapy and Physiotherapy Services

Patient and Clinic Information

Physical Therapy Practice Name

Attending Physical Therapist

Patient Full Legal Name

Date of Birth

Patient ID / Chart Number

Primary Treatment Area

Nature and Purpose of the Treatment

This document records informed consent for physical therapy (physiotherapy) evaluation and treatment services. The care plan may include therapeutic exercise, manual therapy (joint mobilization, soft tissue work), neuromuscular re-education, physical agents (heat, cold, electrical stimulation, ultrasound), and functional training. The physical therapist will conduct an initial assessment to define a treatment plan and discuss clinical goals.

Material Risks and Potential Complications

Temporary increase in muscle soreness, joint stiffness, or mild discomfort following therapy sessions.

Skin irritation, redness, or superficial burns from physical modalities (such as heat packs, ice, or electrical stimulation electrodes).

Risk of falls, muscle strains, or ligament sprains during active exercise training.

Very rare complications associated with manual therapy, including joint strain or nerve irritation.

[Insert additional clinic-specific risk disclosures here]

Expected Benefits

Expected benefits of physical therapy include reduction in pain and inflammation, improvement in range of motion and flexibility, enhancement of muscular strength and endurance, correction of posture and body mechanics, and restoration of physical function.

Reasonable Alternatives

Medical management by a physician, including prescription pain medications, muscle relaxants, or anti-inflammatory drugs.

Interventional options: steroid injections or surgical evaluation by an orthopedist.

Self-directed exercise or choosing not to participate in physical therapy, which may delay recovery or lead to worsening stiffness and weakness.

Financial Responsibility and Billing

I understand that I am responsible for payment of all fees, co-payments, and deductibles at the time of service. I authorize the provider to bill my insurance carrier on my behalf.

Cancellation and No-Show Policy

I understand that appointments must be canceled at least 24 hours in advance. Failure to do so may result in a cancellation fee that is not covered by insurance.

Telehealth Service Acknowledgment

If receiving remote services, I understand the risks and limitations of telehealth, including potential technology failures and privacy constraints outside the clinic setting.

Patient Acknowledgment

I certify that I have read and understand this consent form. I agree to participate in the proposed treatment plan and understand my responsibilities as a patient.

Signatures and Verification

Patient / Authorized Representative Signature

Attending Physical Therapist Signature

Document ID: CC-PENDING

CONSENTCOLLECT