MOMS TREATING MOMS, LLC
Informed Consent and Liability Form
Physical therapy is a patient care service provided in response to a wide range of medical care needs of outpatients of all ages regardless of gender, color, ethnicity, creed, or disability. The purpose of physical therapy is to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis, and intervention. Treatment may consist of rehabilitative procedures, mobilization, massage, exercises, and physical agents to aid the patient in achieving their maximum potential for recovery within their capabilities. All procedures will be thoroughly explained to you before you are asked to perform them. You are expected to fully cooperate with the evaluation and treatment program. Because of the nature of services provided, you may be asked to disrobe. If this is necessary, your privacy, modesty, and dignity will be considered at all times by the staff. Should you feel uncomfortable or embarrassed, you may refuse the procedure, stop the procedure and/or request another therapist.
There are certain inherent risks with physical therapy treatments because you will be asked to exert effort and perform activities with increasing levels of difficulty that could increase your level of pain or discomfort with a current or previous injury. You will be able to stop treatment if you feel any discomfort or pain. Your therapist will take every precaution to ensure that you are protected from any potentially hazardous situation. You will never be forced to perform any procedure that you do not wish to perform. Based on the above information, I agree to cooperate fully, to participate in all physical therapy procedures, and to comply with the plan of care as it is established. I have read the consent form and authorize the release of medical information to appropriate third parties, such as a referring physician for scripts or plan of care authorizations. I hereby release Moms Treating Moms, LLC from any responsibility or liability due to my participation in physical therapy and wellness services.
I am fully aware that I am participating in these sessions at my own risk and will not hold those named above responsible in the event of incurring an injury or exacerbating any previously existing conditions. If I have any medical conditions, I have consulted with my physician to make sure that physical therapy is appropriate for me to participate in.
I also understand that Moms Treating Moms, LLC will maintain my privacy to the highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment.
