Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Physical Therapy Consent Form
Your information
Patient Full Name *
Date of Birth
____ / ____ / ________
Referring Physician
Primary Condition or Diagnosis
Treatment Techniques Authorized
Risks of Physical Therapy Acknowledged
Additional details
Home Exercise Program Commitment
Modalities Consent (e.g., E-Stim, Ultrasound)
Your practice's consent wording goes here.
Signature
Date
Consent to Treatment
Your practice's consent wording goes here.
Signature
Date
Patient Signature
Date
Date of Consent
____ / ____ / ________
Physical Therapy Consent Form template from formisoft.com. formisoft.com/intake-templates/physical-therapy-consent