NEW Patient Forms

Consent, Medical and HIPPA Forms

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  • DeBruin Physical Therapy, LLC

    Informed Consent, Waiver & Release of Liability

    I have volunteered to participate in a program of health care (possibly including but not limited to Physical Therapy,  Personal Training, Wellness, Massage, and Dry Needling) and to retain the services of DeBruin Physical Therapy, LLC. and  its’ employees. I intend to assume all risk of injury from my participation. To that end, I acknowledge and agree to all of the following:
    1. The treatment may include but is not limited to one or more of the following: evaluation, manual therapy, joint mobilization and manipulation, soft tissue mobilization, therapeutic exercise, neuromuscular re-education, therapeutic activities, and dry needling, modalities including but not limited to ultrasound, electrical stimulation, and hot and cold packs. There are inherent risks involved in any evaluation and treatment program. It is not possible to guarantee or give assurance of a successful result. It is important that you understand and agree to the planned treatment. Physical Therapy is generally safe and helpful. However, medical procedures of any type involve the taking of risks, ranging from minor to serious (including the risk of death). It is important to be aware of the following risks before you receive the treatment you and your health care provider are planning.
    2. The possible benefits of this treatment include: decreasing pain, improving cardiovascular fitness, muscle strength, endurance, flexibility, improved body posture, movement and alignment. During treatment there exists a potential for numerous side effects including but not limited to muscle soreness or stiffness; numbness, tingling, or other parasthesias; muscle tears; bony fractures; paralysis; abnormal blood pressure, cerebrovascular accidents, fainting, disorders of heartbeat, and instances of heart attack and death. I assume all of the foregoing risks, and accept personal responsibility for any other damages or other injury I might suffer. I am satisfied with my understanding of the more common risks and complications of the evaluation and treatment.
    3. I know I have the right to choose what treatment I do or do not receive in addition to withdrawing from any treatment at any time.
    4. I understand that a physician’s examination and approval should be obtained prior to participation in a health care program.
    5. I recognize that my participation in the activity covered hereby is conditioned upon my signing and returning this waiver and release. I understand that I may show this INFORMED CONSENT and WAIVER & RELEASE OF LIABILITY to, and consult with, my own independent legal counsel before signing.
    6. DeBruin Physical Therapy, LLC and its’ employees, have not made any representation as to the nature and quality of the facilities or equipment to be used or as to any other matter related to my participation in the foregoing activity. I understand that the “RELEASEES” enumerated above or otherwise owe no duty or obligation to me.
    VIDEO SURVEILLANCE POLICY Acknowledgement, Consent, and Release I understand that in order to promote the safety of employees and company visitors, as well as the security of its facilities, DeBruin Physical Therapy LLC may conduct video surveillance of any portion of its premises at any time, the only exception being private areas of restrooms, showers, and dressing rooms, and that video cameras will be positioned in appropriate places within and around DeBruin Physical Therapy LLC building and used in order to help promote the safety and security of people and property. I hereby give my consent to such video surveillance at any time the company may choose. I hereby release DeBruin Physical Therapy LLC from all liability, including liability for negligence, associated with the enforcement of these policies and/or any searches or surveillance undertaken pursuant to these policies.
    1. I have read and understood this INFORMED CONSENT and WAIVER & RELEASE OF LIABILITY and it accurately sets forth my intentions and I agree to be bound by its provisions.
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