Note: The terms “you” and “your” used below refer to the consenting patient or (if patient is under the age of 18) the patient’s consenting parent/legal guardian on behalf of the patient.

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#1 CONSENT. You consent to physical therapy services at B Active PT LLC. You know if you have any questions about your care, you should be sure to ask the physical therapist about them. You know it is up to you to inform the physical therapist / staff about any health problems or allergies you have. You must also tell the physical therapist/staff about drugs or medications you are taking.

#2 I hereby consent to evaluation and/or treatment of my condition by a licensed physical therapist employed by B Active PT LLC.

#3 The physical therapist has fully explained to me the nature and purposes of the procedures, evaluation and course of treatment.

#4 The physical therapist has informed me of expected benefits and possible complications or discomfort, which may result from skilled physical therapy care. In addition, the physical therapist has explained to me the risks of receiving no treatment.

#5 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.

#6 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.

#7 The physical therapist has explained that there is no guarantee that the proposed course of treatment will improve my condition and that is possible, although unlikely, that the course of treatment may cause additional pain or discomfort or aggravate my condition.

#8 If I have trouble with any part of my treatment program, I will discuss it with my therapist.

#9 The term “informed consent” means that the potential risks, benefits, and alternatives of physical therapy treatment have been explained to me. 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.

#10 I have been given on opportunity to ask questions, and all my questions have been answered to my satisfaction.

#11 I confirm that I have read and fully understand this consent form. In the event of a change in medical status, I understand that my treatment may be

modified, stopped, or referred out to the proper practitioner. I reserve the right to withdraw at any time.

#12 FINANCIAL. Payment is due at time of service.

#13 NO GUARANTEES. You understand that the practice of physical therapy is not an exact science and that no guarantees or promises have been made to me as a result of treatments or examinations by the physical therapist. You understand that no contract, warranty, guarantee, or promise concerning the results of the physical therapy services is made. This consent to treatment form is not a contract, nor is it an offer to contract, nor is it an acceptance of an offer to contract.

#14 CANCEL / NO SHOW / LATE POLICY. If you must cancel your scheduled appointment, a 12-hour notice is required. No-shows or Cancels with a less than 12-hour notice will result in a fee equal to 50% of treatment fee. No-shows will result in a full visit fee.