Please fill out this form AFTER you have made an appointment at Physicians Quality Care Physical Therapy.
Please carefully read the following statements and sign at the bottom indicating your understanding. If you have any questions, direct them to your therapist.
Consent to Evaluation/Treatment
I hereby consent to the evaluation and/or treatment of my condition by a licensed physical therapist employed by Physicians Quality Care.
Course/Risk of Treatment
The physical therapist has fully explained to me the nature and purposes of the procedures, evaluation and course of treatment. 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. The physical therapist has also explained that physical therapy is not an exact science and there is not a guarantee that the proposed course of treatment will improve my condition. In addition, the physical therapist has explained that it is possible, although unlikely, that the course of treatment may cause additional pain or discomfort or aggravate my condition.
Patient Responsibility
- It is the patient's responsibility to inform the physical therapist of all medical conditions, treatments, and medications at their initial visit (i.e. complete the physical therapy health history form).
- It is the patient's responsibility to inform the physical therapist as soon as possible if there has been any change in medical or insurance status.
- It is the patient's responsibility to inform the physical therapist if the patient is under the influence of any substance that may affect the safety of their treatment (drugs, alcohol, pain killers, blood thinners, etc.).
Cancellation/Late Policy/No Show Policy
- If you must cancel your scheduled appointment, please provide a 24-hour notice if possible. Physicians Quality Care Physical Therapy may be contacted at 731-984-7098.
- If you arrive 10 minutes or more late for your appointment, your physical therapist reserves the right to reschedule your appointment.
- If you do not show up to two consecutive appointments, your physical therapist reserves the right to cancel your remaining scheduled visits if we cannot contact you or no attempt has been made to contact our department.