1160 Suncast Ln El Dorado Hills, CA

Transcription

1 1160 Suncast Ln El Dorado Hills, CA PATIENT INFORMATION Name: Birth date: Parent/Guardian name (if patient is a minor): Address: Cell phone: Home Phone: Emergency contact: Referring Physician: Financial Policy: Plachy Physical Therapy is a fee for service clinic (I do not bill insurance). I understand that I am agreeing to pay cash at the time of each treatment for the services I receive at Plachy Physical Therapy. By signing this agreement, I am agreeing to pay cash for each treatment, even if I have health insurance. I am choosing not to use my health benefits for treatment received at Plachy Physical Therapy. If I have insurance, I further understand that if I choose at a later date to utilize my insurance benefits that this cannot be done retroactively and cannot be used for future dates of service. I agree to pay Plachy Physical Therapy for treatment at the time of service, by cash or check, unless other mutually agreed upon arrangements have been made. Patient signature:

2 CONDITIONS FFOR TREATMENT: I understand that the physical therapist cannot make any promises or guarantees regarding my progress or improvements as a patient. I understand that I as a patient must participate in the treatment plan outlined by the physical therapist, including performing home exercises and practicing suggestions made by the physical therapist regarding performance of daily activities, etc. Failure to do so will negatively affect my progress as a patient. If I have any problems or concerns regarding my treatment, I agree to discuss them with the physical therapist immediately. By signing this form, I agree with the conditions stated in this form: Patient/Guardian signature: Print patient name: Date: CONSENT FOR TREATMENT: The term informed consent means that the potential risks and benefits of physical therapy treatment have been explained to the patient. I hereby consent to physical therapy treatment. POTENTIAL RISKS: You may experience an increase in your symptoms, or an aggravation of your existing condition. These symptomatic increases are usually temporary, and usually resolve within 1-2 days. If this increase in symptoms does not subside in 2 days (48 hours), I agree to contact and inform the physical therapist. I may experience bruising and temporary soreness as a result of the treatment I receive. I may notice temporary changes in my gastrointestinal regularity (increased or decreased regularity of bowel movements, etc) as a result of abdominal region treatment. POTENTIAL BENEFITS: As a result of manual treatment, you may experience a decrease in your symptoms, improved mobility of the treated areas, improved ability to perform my daily activities or recreational/sporting activities. You will be educated regarding strategies for maintaining and improving your ability to function on a daily basis and maintaining your decreased levels of pain.

3 CONSENT FOR TREATMENT, continued. I understand that my treatment may include manual therapy, which may or may not include the physical therapist s hand placement NEAR (not on) the breast tissue and genitalia. The physical therapist may need to touch the patient s buttock area as well with certain treatment techniques. I understand that it is my responsibility to inform the physical therapist if I am not comfortable with any of the manual treatments provided, and that I do not have to participate in these treatments. If I express unwillingness to continue, the treatment technique will be terminated immediately. The physical therapist will ask for verbal consent from the patient for these techniques, will explain what he intends to do with these treatments and explain the rationale for each treatment provided. I grant permission to Michael Plachy, MPT, CFMT to perform manual therapy techniques, exercise instruction, therapeutic exercise, neuromuscular re-education techniques and any other techniques believed to be beneficial for my condition. Patient s initials: CONSENT FOR MUTUAL EXCHANGE OF INFORMATION: I authorize the mutual exchange of information regarding myself between Plachy Physical Therapy and the following persons or professionals: AKNOWLEDGEMENT OF RECEIPT OF OR UNDERSTTANDING OF PRIVACY NOTICE: I consent to the use and disclosure off protected health information about me for treatment, payment and health care operations. I acknowledge that I have received a copy of your condensed NOTICE OFPRIVACY PRACTICES. I know that I have the right to receive a complete detailed copy of the privacy notice upon request. Patient s initials: I have read, and fully understand all of the statements made on this form and agree that they apply to all treatments I receive from Plachy Physical Therapy, and from Michael Plachy, MPT, CFMT. I understand that I am responsible for all services received, and agree to pay for any and all services rendered at the time of service, unless previous arrangements have been made.

4 Printed name: Signature of patient/guardian: Date: Date of birth: Reason for treatment: Goals: CIRCLE ALL AD ANY OF THE CONDITIONS TTHAT APPLY TO YOU AND ELABORATE NEXTT TO THE LISTED CONDITTION: Cancer Heart disease/chest pain High blood pressure Pacemaker Diabetes Stroke thyroid problem Seizures Difficulty breathing Dizziness/vertigo Fainting/loss of consciousness Allergies/symptoms related to allergies AREAS OF PAIN: Lower back pain Mid back pain Neck pain

5 Headaches Jaw pain Tailbone pain Pelvic region pain SI joint pain Abdominal pain Shoulder pain Arm pain/elbow/wrist/hand pain Hip pain Knee pain Ankle/foot pain sciatica Carpal tunnel Migraine headaches SURGICAL HISTORY: Back or neck Joint replacements Arthroscopic surgeries Abdominal/pelvic surgeries ANY AND ALL other surgeries: FAMILY HISTORY: Heart disease High blood pressure Diabetes, Cancer Osteoporosis

6 CIRCLE ALL WHICH DESCRIBE YOUR SYMPTOMS: Numbness Tingling Shooting Stabbing Burning Aching Throbbing Other: WHICH ACTIVITIES MAKE YOUR SYMPTOMS WORSE? Sitting Standing Walking Getting out of bed Getting up from sitting Sleeping Work tasks Morning Night time Household chores Sexual intercourse

7 ACTIVITIES WHICH WORSEN SYMPTOMS, CONT: Sports/recreation Other: ACTIVITIES WHICH IMPROVE MY SYMPTOMS: Heat Ice Rest in bed Movement Exercise Stretching Walking Medication PLEASE CHECK ALL OF THE FOLLOWING STATEMENTS THAT APPLY TO YOUR CONDITTION: I get dizzy frequently I have blurry vision at times Bowel or bladder function changes Decreased sensation in the genital/anal region Numbness/tingling in the feet/hands Unexplained weight loss WHICH PREVIOUS TTREATMENTS HAVE YOU RECEIVED FOR THIS CONDITION?: Physical therapy Chiropractic Acupuncture Massage

8 PREVIOUS TREATMENT FOR PRESENT CONDITION, CONT: Medication Surgery PLEASE LIST MEDICATIONS YOU ARE PRESENTLY TAKING: What is the goal you wish to achieve through treatment at Plachy Physical Therapy?

9 1160 Suncast Ln El Dorado Hills, CA Plachy Physical Therapy Privacy Statement I understand that Plachy Physical Therapy will maintain my privacy to the highest standards and may use or disclose my personal health information for the purpose of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. Photographs, which may be taken during initial evaluation, progress evaluations and discharge summaries will be used for postural comparison purposes as well as educational tools. By signing below I consent to the use of these photographs for professional purposes. I do hereby agree and give my consent for Plachy Physical Therapy to furnish care and treatment that is considered necessary and proper in the diagnosing and 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 hereby certify that all of the above information is true to the best of my knowledge. Patient/parent/guardian signature Date

10 1160 Suncast Ln El Dorado Hills, CA Consent for treatment of a minor at Plachy Physical Therapy I, give my written consent for my child, to receive treatment at Plachy Physical Therapy without me being present. Parent/Guardian signature Date

11 1160 Suncast Ln El Dorado Hills, CA If you are seeking Physical Therapy services directly, without a referral from an M.D. or D.O., the Physical Therapist is obligated by California law to inform your Primary Physician that you are doing so, with your written/signed approval. Please sign below if you approve of Mike Plachy, MPT, CFMT informing your Physician that you are seeking Physical Therapy services directly, without a referral at this time. With your signature, a copy of your P.T. evaluation will be faxed to your Physician. Signature of patient date Printed name