Total Body Screen Informed Consent
Privacy and Sharing of Information:
You authorize ACE Physio & Performance, PLLC, and its associated health professionals to collect your personal and medical information. In addition, you authorize ACE Physio & Performance, PLLC to communicate with your family physician and/or referring medical health provider as deemed necessary for your beneficial treatment. You also understand that your personal and medical information is confidential and will only be disclosed to third parties with your permission.
Patient Rights and Responsibilities:
You have received a copy of the patient privacy information form and understand it.
You authorize ACE Physio & Performance, PLLC to collect and publish photos and/or videos of your treatment. Photographs taken during workshops, total body screen, initial evaluation, progress evaluation, and discharge summary can be used for postural comparison purposes and as educational tools. These photos/videos could be used for promotional and informational marketing material. By signing below you consent to the use of these photographs in a professional manner without any form of reimbursement.
You agree that ACE Physio & Performance, PLLC can stop providing care at any time for any reason. You agree and acknowledge that you may have additional people present at the time of the appointment. By requesting additional people be present at your appointment, you agree and acknowledge that you are authorizing the release of medical information to such individuals in the form of any discussions that take place during such appointment.
Due to the nature of private therapy, ACE Physio & Performance, PLLC requires that a parent or legal guardian be present during appointments for minors.
Acknowledgement of Receipt of Notice of Privacy Practices:
You have been given a copy of the “Notice of Privacy Practices” that describes how your health information may be used and disclosed and how you can access your health information. You understand that the notice may be changed at any time as permitted by applicable law. You may obtain a current copy of the notice by contacting ACE Physio & Performance, PLLC.
Permission for Treatment:
ACE Physio & Performance, PLLC is a hands-on Physical Therapy clinic. Highly specialized treatment consists primarily of manual therapy techniques and treatment forms that are published or otherwise publicly known, such as, forms of electrical stimulation, deep tissue massage, therapeutic exercise programs, neuromuscular re-education, comprehensive dry needling, myofascial release, bone and soft tissue manipulation, as well as other treatment modalities may be used. Some of the hands-on treatment techniques require deep pressure or the use of needles which may cause bruising and periods of increased soreness which may last from 6-72 hours. Your therapist will review your plan of care and discuss these treatment options with you for you to provide specific consent. Symptoms may also change and move to other parts of the body, this is not unusual and is rarely a concern; however, please ask if you have any concerns or questions. The number of treatments needed and recovery time can vary due to the age of injury, number of times injured, age of patient, and many other contributing factors. You acknowledge that all or a portion of your treatment may take place in an open and/or non-private setting, such as the gym floor, where third parties not employed by or affiliated with ACE Physio & Performance, PLLC may be present. You are aware of and consent to the fact that these third parties may overhear some of your protected health information during care and/or observe your course of treatment. Should you need to speak with your treatment provider in total privacy, you understand that your treatment provider will furnish a room for these conversations. You give permission to ACE Physio & Performance, PLLC to perform the necessary testing and treatment according to your diagnosis. You agree that no guarantee or promise has been made as to the results of services you are to receive nor that any treatment you receive will produce specific results. You understand that you retain the right to revoke this consent by notifying the practice in writing at any time.
Your signature below indicates that you have been provided with a copy of the “Notice of Privacy Practices.” You agree and acknowledge that a photocopy or PDF version of this signed agreement will be as valid as the original. You agree that should you have any disputes with ACE Physio & Performance, PLLC that the state law will govern such disputes and that such disputes must be held at a court located in the county where you receive treatment.