CONDITIONS & CONSENT FOR TREATMENT I understand that I am a patient of Foundational Concepts, Pelvic Wellness Center, independent healthcare practitioners. My care is the exclusive responsibility of my treating therapist, not of any other practitioners who also may practice at this location.Cooperation with TreatmentSchedule Agreement In order for physical therapy treatment to be effective, I must come to scheduled appointments unless there are unusual circumstances. I understand and agree to cooperate with and perform the home therapy program intended for me. If I have trouble with any part of my treatment program, I will discuss it with my therapist. Cancellation Policy I understand that if I cancel more than 24 hours in advance, I will not be charged. I understand that if I cancel less than 24 hours in advance, I will pay a cancellation fee of $75. If I do not show for my appointment and do not call to cancel I will pay the full fee of $125.00 for my treatment session.No Warranty I understand that there are no guarantees regarding a cure for or improvement in my condition. I understand that my physical therapist will outline and discuss goals of therapy treatment for my condition and will discuss treatment options with me before I consent to treatment.I agree to the above conditions* By checking this box I am agreeing to these conditions Informed Consent for TreatmentThe term “informed consent” means that the potential risks, benefits, and alternatives of physical therapy treatment have been explained to you. The therapist provides a wide range of services and I understand that I will receive information at the initial visit concerning the treatment and options available for my condition. This may include vaginal or rectal exam, surface EMG, biofeedback with a rectal balloon, or dry needling.Potential Risks 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 24 hours, I agree to contact my physical therapist.Potential Benefits May include 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.Alternatives If I do not wish to participate in the therapy program, I will discuss my medical, surgical or pharmacological alternatives with my physician or primary care provider.I agree to the above conditions* By checking this box I am agreeing to these conditions Medical Records Release Authorization I authorize the release of my medical records to the following physicians/primary care provider or insurance company. REQUIREMENT: You must include a physician's name in at least one of the entries below.Provider/Company Name If you need to list more than one provider/company, click on the plus sign (to the right) to add a row.Financial and Insurance ResponsibilitiesI agree to pay for my treatments at time of service, by cash, check, or charge card unless other mutually agreed upon arrangements have been made. I understand it is my responsibility to call my insurance company ahead of time, and obtain any pre-authorization that is necessary, and get an estimate of my benefits. I understand my therapist will submit my claim to my insurance company. I understand that if my evaluation is scheduled on or after May 1, 2018, $25 of the fees collected at my evaluation are facility fees and are not billable to insurance, therefore not qualified for reimbursement or application to my deductible. In the event a patient is not seen in clinic for consecutive 3 months, the patient will be discharged from therapy and will require a new referral or evaluation to resume physical therapy services.I agree to the above conditions* By checking this box I am agreeing to these conditions Signature ApprovalI have read all of the above information and I consent to physical therapy evaluation and treatment.Name* First Last Today's Date* Patient or Guardian Signature* This iframe contains the logic required to handle Ajax powered Gravity Forms.