NEW Patient Forms Consent, Medical and HIPPA Forms Step 1 of 4 25% 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: 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. 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. 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. I understand that a physician’s examination and approval should be obtained prior to participation in a health care program. 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. 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. 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. Patient Name* First Last Guardian Name (if applicable) First Last Email* Date* MM slash DD slash YYYY Some insurances may require preauthorization for out of network providers. Understanding individual insurance plan benefits is the responsibility of the patient. Payment is due at the time of service.* I Understand and Agree to these terms. E-Signature* By checking this box you are confirming that all information provided above is accurate. Initials* DeBruin Physical Therapy, LLC Medical Intake FormAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Physician Name* Physician Phone*DOB* MM slash DD slash YYYY Medical Information: To the Best of your knowledge, do you have or have you had (CHECK ALL THAT APPLY): High Blood Pressure Heart Disease / Heart Attack Chest Pains / Angina High Cholesterol Pacemaker Shortness of Breath Asthma Allergies Chronic Bronchitis Blood Disorders Emphysema Bleeding / Bruising Anemia Diabetes Hypoglycemia Lightheadness Dizziness Concussion Fainting Disorders Anxiety / Panic Attacks Arthritis / Joint Pain Artificial Joints Kidney Disease / Stones Hepatitis Spinal Cord Injury Traumatic Brain Injury Ulcers Blood in Stool/Ulcers Abdonminal Pain Thyroid Problems Polio / Muscle Disease Seizures Migraine / Cluster Headaches TMJ Disorders Chills/Fever/Sweats Chronic Headaches Swelling of Extremities Sleep Disorders Depression Fibromyalgia Chronic Fatigue Syndrome Lyme Disease Chronic Pain Night Pain Unexplained Pain Unexplained Weight Loss Cancer / Tumors / Growths History of Smoking Are you pregnant? Gynecological Disorders Bladder Incontinence Bowel Incontinence Fractures If you've had Fractures, please state the date and area of fracture:Reason for seeking Physical Therapy*Current Medications:Allergies (Medications and Other Substances):Surgery(s) Include Dates:X-Rays, MRI(s), Cat Scan(s) - Include area & dates:E-Signature* By checking this box you are confirming that all information provided above is accurate. Initials* DeBruin Physical Therapy, LLC Self Evaluation Three activities you would most like to be able to do without any difficulty:*Primary activity you would most like to be able to do without any difficulty:*Select the level of difficulty you have for each activity today.Self Evaluation*1 - Able to do without any difficulty2 - Able to do with little difficulty3 - Able to do with moderate difficulty4 - Able to do with much difficulty5 - Unable to do9 - Not applicableLying flatRolling overMoving-lying to sittingSittingSquattingBending/stoopingBalancingKneelingStandingWalking-short distanceWalking-long distanceWalking-outdoorsClimbing stairsHoppingJumpingRunningPushingPullingReachingGraspingLiftingCarrying DeBruin Physical Therapy, LLC HIPPA Consent I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPPA). I understand that by signing this consent, I authorize DeBruin Physical Therapy, LLC, its employees, and agents to use and disclose my protected health information to carry out: Treatment, including direct or indirect treatment by other healthcare providers involved in my care Obtaining payment from third party payers (insurance companies) The day-to-day administration of this practice I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and business operation. I also understand that DeBruin Physical Therapy, LLC is not required to agree to any such restrictions, but that if it does agree, it will be bound to comply with any and all restrictions to which it agrees. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date of revocation will not be affected.Patient Name* First Last Guardian Name (if applicable) First Last Date* MM slash DD slash YYYY E-Signature* By checking this box you are confirming you agree with the terms listed above. Initials*
