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Physical Therapy Consent Form
Consent

Physical Therapy Consent Form

2 pages•13 fields•HIPAA-ready
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Physical Therapy Consent Form
Patient Full Name
Date of Birth
Referring Physician
Primary Condition or Diagnosis
Treatment Techniques Authorized
Risks of Physical Therapy Acknowledged
Home Exercise Program Commitment
Modalities Consent (e.g., E-Stim, Ultrasound)
I agree to the terms above
Sign here
Consent to Treatment
I agree to the terms above
Sign here
Patient Signature
Sign here
Date of Consent
Submit
Use this template

The Physical Therapy Consent Form is designed for outpatient rehabilitation clinics, hospital-based physical therapy departments, and sports medicine practices. It ensures patients understand the nature of physical therapy treatment, the techniques that may be used during their sessions, and their active role in the rehabilitation process.

This template addresses a range of therapeutic interventions including manual therapy, therapeutic exercises, modalities such as electrical stimulation and ultrasound, dry needling, and aquatic therapy. It clearly outlines potential risks including temporary soreness, muscle fatigue, and the rare possibility of injury during treatment. The form also documents the patient's commitment to following their home exercise program and attending scheduled sessions.

Appropriate for physical therapy private practices, hospital outpatient rehab departments, sports medicine clinics, and occupational therapy settings, this form helps practitioners meet informed consent requirements while fostering a collaborative therapeutic relationship built on clear communication and mutual expectations.

What's included

  • Patient identification and referring physician details
  • Primary condition and diagnosis documentation
  • Treatment technique and modality authorization
  • Risk disclosure and acknowledgment
  • Home exercise program commitment statement
  • Patient signature and date fields
  • Consent agreement with e-signature

Who uses this template

  • Onboarding new patients for outpatient physical therapy programs
  • Documenting consent for manual therapy and therapeutic modalities
  • Recording patient commitment to home exercise and attendance expectations
  • Meeting informed consent requirements for sports rehabilitation services

All form fields

11 fields across 2 pages. Customize any field after signing up.

Patient Full NameText
Date of BirthDate
Referring PhysicianText
Primary Condition or DiagnosisText
Treatment Techniques AuthorizedCheckbox
Risks of Physical Therapy AcknowledgedCheckbox
Home Exercise Program CommitmentCheckbox
Modalities Consent (e.g., E-Stim, Ultrasound)Consent Agreement
Consent to TreatmentConsent Agreement
Patient SignatureE-Signature
Date of ConsentDate

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