Informed Consent for Treatment

Please select which location you are submitting this form to:

Thank you for choosing Nose Creek Sport Physical Therapy. Although we offer the best care and possess the skills to return you to a state of health it requires teamwork. Without commitment to your treatment plan we will not be successful. Please read and sign this form prior to your treatment and address any concerns with your therapist. We're glad you're here and promise to make your sessions all about YOUR RECOVERY.

  1. I understand my therapist will discuss treatment options with me and my treatment plan may include education, therapy, modalities and active exercise.
  2. I understand that there may be risks if I do not disclose my full health history. I understand that my therapist will educate me on the acceptable pain levels, expectations and management during my care/recovery. I appreciate that while rare, strains, or burns may result from my treatment.
  3. I understand that my progress will be monitored throughout my treatment and that I will have reassessments as indicated.
  4. I understand that based on my response, my goals and my reassessment findings that my treatment may be altered accordingly.
  5. I understand not complying with my prescribed treatment plan may cause, no change in my signs or symptoms, delayed recovery and/or not achieving my goals.
  6. I understand that alternative therapies (i.e., Massage Therapy) or products (bracing, taping) may be warranted for my case. The corresponding health care provider will be responsible for explaining the benefits and risks.
  7. I understand that a Physical Therapy Assistant will assist my therapist in delivery of my care and are following the plan developed and directed by my therapist. I understand the therapist will communicate with my physician or other parties as needed.
  8. I understand that students under supervision may assist in the delivery of my care.
  9. I understand that many factors play a role in achieving full recovery. I may not fully achieve my initial goals and my expectations for recovery may need to be adjusted. My therapist will review the typical recovery timelines with me; however, variances may occur depending on individual circumstances.
  10. I understand that I may withdraw my consent at any time. This consent will apply to my treatment going forward.

  I have read, understood and accept the above