Privacy and Sharing of Information

I authorize the clinic and its associated health professionals to collect my personal information as documented above. I also understand that my personal information is confidential and will only be disclosed to third parties with my permission.

Informed Consent for Remote Consulation/Coaching

“Informed Consent” is a process for getting permission before we provide coaching services to you, the client. A sound informed consent includes an explanation of the potential risks, benefits, and alternatives to any treatment or exercises that has been proposed to you or, in the case of a minor, your representative. We will discuss the plan established for you and give you ample time to ask questions about it; your consensus is a critical part of achieving a successful outcome.

Potential Benefits: You may experience improvement in your symptoms and functional activities as well as resolution of other key complaints or problems. In addition to coaching/programming, we provide education to you about your condition throughout your episode of care. This education is often accompanied by handout material that you can refer to regarding proper techniques and home program execution. These resources will help you maintain a sound level of function and will also help you minimize symptoms, should they reoccur.

Potential Risks: You may experience an increase in your current level of pain, if pain is part of your complaints. Many times increased activity or interventions will bring on some discomfort, this is usually temporary. If your pain or discomfort does not subside within twenty-four (24) hours, you should discontinue any home program involving that particular activity, if applicable, and contact your provider.

Alternatives: We establish a plan based on the best interventions for your condition and goals, but on occasion our choice of treatment is not well tolerated. You are asked to voice any unfavorable reaction you experience to any aspect of your treatment so that we can modify or terminate it promptly and progress your care. If you decide not to continue your participation in your program you will be asked to consult with your physician about other treatment alternatives. No Warranty: Please note that we cannot make any promises or guarantees regarding a full resolution of and/or correction of your condition or goals. We will, however, work in conjunction with you to achieve optimal improvement.

Financial Agreement

Lewis Physical Therapy & Sports Rehabilitation requires that a one-time, non-refundable payment is due from the client at time of service. I agree to pay at time of service by credit card unless other mutually agreed upon arrangements have been made.