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Informed Consent for Physical Therapy Treatment


I hereby consent to evaluation and/or treatment of my condition(s) by Dr. Sara Ziegele, PT (my physical therapist).

I understand that my physical therapist will continuously explain the nature and purpose of procedures, evaluation, the course of treatment at my physical therapy sessions. I understand that this form outlines the benefits and risks of receiving physical therapy services.

The physical therapist will inform me of expected benefits and possible complications or discomfort, which may result from skilled physical therapy care. In addition, I understand that withdrawing from treatment may result in no improvement or worsening of my condition(s).

I understand that I may experience an increase in my current level of pain or discomfort, or an aggravation of my existing injury or condition. This discomfort is usually temporary; if it does not subside in a reasonable time period, I agree to contact my physical therapist.

I may experience an improvement in my symptoms and an increase in my ability to perform daily activities. I may experience increased strength, awareness, flexibility and endurance in my movements. I may experience decreased pain and discomfort. I should gain a greater knowledge about managing my condition and the resources available to me.

I understand that there is no guarantee that the proposed course of treatment will improve my condition and that it is possible, although unlikely, that the course of treatment may cause additional pain or discomfort or aggravate my condition.

In order for physical therapy treatment to be effective, I understand and agree to cooperate with and perform the physical therapy program intended for me. If I have trouble with any part of my treatment program, I will discuss it with my physical therapist.

The term “informed consent” means that the potential risks, benefits, and alternatives of physical therapy treatment have been explained to me in this document. The therapist provides a wide range of services and I understand that I will receive information concerning the treatment and options available for my condition.

I understand that I can ask my physical therapist questions at any time throughout the course of my care and that I can withdraw from any treatment at any time during the course of my care. I confirm that I have read and fully understand this consent form. I understand that my treatment may be modified, stopped, or referred out to the proper practitioner based on the Physical Therapist's expertise and judgment.

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