Concierge Physical Therapy

I, the undersigned, do hereby agree and give my consent to Concierge Physical Therapy, to furnish me with physical therapy care that is considered necessary and proper in diagnosing or treating my physical condition.

I have had full opportunity to read Concierge Physical Therapy Notice of Privacy Practices. I understand that by signing this consent, I am giving my consent to Concierge Physical Therapy to use and disclose my protected health information to carry out treatment, payment activities and health care operations. I understand the terms of this notice may change with time and Concierge Physical Therapy will always post the current notice at the clinic, on the website and have copies available for distribution.

I have had full opportunity to read Concierge Physical Therapy arbitration agreement. I understand that by signing this consent, if a dispute arises from or relates to this physical therapy engagement, and if the dispute cannot be settled through direct discussions, the parties agree to endeavor first to settle the dispute by mediation administered by the American Arbitration Association under its Healthcare Payor Provider Mediation Procedures before resorting to arbitration. The parties further agree that any unresolved controversy or claim arising out of or relating to this physical therapy engagement, shall be settled by arbitration administered by the American Arbitration Association in accordance with its Healthcare Payor Provider Arbitration Rules and judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof.