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New Client Intake Form

PHYSICAL THERAPY POLICIES AND PROCEDURES

We want your informed consent. This means that we want you to understand the services we hope to provide to you, the risk involved in exercise participation, the cost involved, and what we do with personal information we obtain about you. If you have a question on any of this, please ask.

CONSENT FOR THE COST OF OUR SERVICES

Payment is due at the time services are provided. Acceptable methods of payment are cash, check, a credit card that is linked to an HSA (health savings account), or a regular credit card. Insight Pelvic Health is not an in-network provider for any insurance carrier, and does not provide direct billing to insurance carriers. You will be provided an invoice upon request that you may file with your insurance or medical savings plan for out-of-network reimbursement. ​You are responsible for understanding your benefits for an out-of-network provider.

Insight Pelvic Health Consent for Treatment and Medical Assistance

I certify that the demographic and health history information I have provided is correct. I understand that there are risks involved in participating in any exercise program. I certify that I have been cleared by my doctor to participate in an appropriate exercise program that includes physical strain and exertion. I assume all such risks by requesting entry into this physical therapy program. I consent to evaluation, treatment, and fitness program consultation. I consent to the use of photography (still and video) as an evaluation tool, to demonstrate exercises, and to document progress. I hereby release, discharge and acquit Insight Pelvic Health, it’s agents, representatives, affiliates, employees or assigns, of and from any and all liability, claim, demand, damage, cause of action or loss of any kind arising out of or resulting from my refusal to accept, receive or allow emergency and or medical services including but not limited to ambulance services, Emergency Medical Technicians, physician or urgent care services. I have read, understood and agree to the policies stated above.

Insight Pelvic Health Scope and Methods of Care

I acknowledge and understand that I have been referred for evaluation and treatment of pelvic floor dysfunction or other condition. Pelvic floor dysfunctions include, but are not limited to: urinary or fecal incontinence, difficulty with bowel, bladder, or sexual functions, painful scars after childbirth or surgery, persistent pubic, sacroiliac, or low back pain, diastasis recti, or pelvic pain conditions. I understand that to evaluate my condition it may be necessary, initially and periodically, to have my physical therapist perform an internal pelvic floor muscle evaluation. This evaluation is performed by observing and/or palpating the perineal region including the vagina and/or rectum. This evaluation will assess skin condition, reflexes, muscle tone, length, strength, endurance, scar mobility, and function of the pelvic floor region. Such evaluation may include vaginal or rectal sensors for muscle biofeedback. I understand that treatment may include, but not be limited to, the following: observation, palpation, functional dry needling, use of kinesio tape, visceral mobilization, stretching and strengthening exercises, soft tissue and/or joint mobilization, and patient and/or family education. I understand that I may experience an increase in my current level of pain or discomfort, or an aggravation of my symptoms. The discomfort is usually temporary; if it does not subside in 24 hours, I agree to contact my physical therapist. I understand that I may experience improvements including, but not limited to, decreased pain or discomfort, increased awareness of my condition and greater ability to manage it, increased capability of performing my daily activities and maintaining sustained postures such as sitting, standing, etc., and/or increased strength, endurance, range of motion, flexibility, and ease of movement. However, I understand that Insight Pelvic Health cannot make me a guarantee of a cure for or improvement in my condition. I understand that in order for physical therapy to be effective, I must participate as scheduled unless there are unusual circumstances that prevent me from attending therapy. I agree to cooperate with and carry out the home program assigned to me. If I have difficulty with any part of my treatment program, I will discuss it with my physical therapist.

Provider Electronic Signature I have read and agree to the Policies and Procedures of Insight Pelvic Health, Consent for Treatment and Medical Assistance, Consent for Cost of Services, and Scope and Methods of Care. *

CANCELATION POLICY​

Should you need to cancel an appointment for any reason, it must be done at least 24 hours in advance. Failure to do so will result in a $50.00 fee. Missed appointments or cancellation of an appointment less than 1 hour in advance will result in a charge equal to the full price of the appointment, $295 for evaluations and $205 for follow-up appointments.

Attestation: I have read and understood the Insight Pelvic Health cancellation policies and I agree to be bound by its terms. *

Insight Pelvic Health Consent for Communication with Care Team

I understand that Insight Pelvic Health will maintain my privacy to the highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. Photographs taken during initial evaluation, progress evaluation and discharge summary will be used for postural comparison purposes and as educational tools. By signing below, I consent to the use of these photographs in a professional manner. I do hereby agree and give my consent for Insight Pelvic Health to furnish care and treatment that is considered necessary and proper in the diagnosing or treating of my physical condition. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time. I understand that to provide me with physical therapy services, Insight Pelvic Health will collect some personal information about me (e.g. home telephone number, address, health history, social history). I agree to Insight Pelvic Health collecting, using and disclosing personal information about me as set out above and in the Insight Pelvic Health Privacy Policy. I consent to allowing Insight Pelvic Health to discuss the health information collected during my evaluation and ongoing treatment, my progress, changes in my condition, and physical therapy plan of care with referring practitioners, other allied health professionals and fitness professionals for the purpose of coordinating care and optimizing treatment outcomes. Should my therapist need to reach me outside of appointment times, I consent to be contacted by the means listed in my intake forms.

By signing below you agree to terms of the Consent for Communication with Care Teams. *

Insight Pelvic Health Electronic Communication Consent

Email Authorization: Insight Pelvic Health is equipped to relay information to you using email. Due to the “HIPPA Notice of Privacy Practices” we need your permission to communicate with you electronically. Please note, although every effort is made to ensure patient privacy, Insight Pelvic Health cannot assure confidentiality of information sent electronically or be held liable for security risks.

By signing below, you grant permission for practitioners and staff of Insight Pelvic Health / Insight Physical Therapy and Wellness, PLLC to contact you via email to discuss your care. Additionally, you agree to receive SMS notifications regarding upcoming appointments.