I hereby consent to evaluation and/or treatment of my condition by Sasha N. Torres, DPT a licensed physical therapist with Rehab Concierge Services, LLC. The physical therapist has fully explained to me the nature and purposes of the procedures, evaluation and course of treatment, and with my signature of this form I hereby consent to this skilled 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 explained that there is no guarantee that the proposed course of treatment will improve my condition and that it is possible, although unlikely, that the course of treatment may cause additional pain, discomfort or aggravate my condition. I have been given an opportunity to ask questions, and all my questions have been answered to my satisfaction. In signing this form, I also confirm I have given an accurate medical history and current medication information to the best of my ability.  I confirm that I have read and fully understand this consent form.

 

If the patient is a minor (less than 18 years old), I acknowledge that I am the legal parent or guardian of this child and hereby consent for his/her physical therapy treatment.