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If patient is under the age of 18, parent or guardian must be present during the treatment session. An older child can be treated without the parent present if the parent has given signed consent and is reachable by phone at all times during the session

Symptoms:

Thank you for your time in filling this out! This will speed up treatment and allows me to be more laser in diagnosis.

Suzanne Joseph, DPT, IMTC

Present-time Information:

Please list the physicians involved in your child’s care. We will ask you about who we can contact to coordinate your care.

ABOUT OUR CARE:

While all therapies are hands-on, they are effective and gentle. There is no pain in ANY treatment. Clothing should be light and stretchy. Please avoid jeans or denim, non-stretchy materials. Please bring books to read to your child, interactive toys, or a video.

We do require that parent/guardian or other designated adult be present throughout pediatric sessions. This is necessary for further discussion regarding ongoing patient needs.

Dear Patient:

At your initial evaluation, you will have the findings and treatment plan discussed with you. The recommendations will be documented and are shared as needed with your chosen insurance company and by law with your physician.
ANY alteration of the treatment plan effects the outcome.

We may, at the initial evaluation, determine that you would do better to return to your doctor so that your concerns about your treatment plan can be answered. The doctor may also be better able to explain to you the importance in following your treatment plan for the benefit of your general health. With your full understanding and anticipated compliance, we will be happy to get you scheduled as soon as possible.

Please sign signifying your understanding of this action.

I request and authorize Hands On Health Manual & Physical Therapy Services, LLC to release healthcare information of the patient named above to:

This request and authorization apply to:

Dear Patient:

E-mail offers an easy and convenient way for patients and doctors to communicate. In many circumstances, it has advantages over office visits or telephone calls. We believe that the ease of communication e-mail affords is a benefit to patient care. It will further assist us if you could identify the nature of your request in the subject line of your message. Below are our rules for contacting us using e-mail.

E-mail is never, ever, appropriate for urgent or emergency problems! Please use the telephone or go to the Emergency Department for emergencies.

E-mail is great for asking those little questions that don’t require a lot of discussion. Appropriate uses of e-mail also include referral and appointment scheduling requests and billing/insurance questions.
E-mails should not be used to communicate sensitive medical information, such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability, or substance abuse.

E-mail is not confidential. It is like sending a postcard through the mail. My staff may read your e-mails to handle routine, non-clinical matters. You should also know that if sending e-mails from work, your employer has a legal right to read your e-mail if he or she chooses.

E-mail may become a part of the medical record when we use it; a copy may be printed and put in your chart.

E-mail is not a substitute for seeing me. If you think that you might need to be seen, please call and book an appointment!

E-mails may be forwarded to my staff for handling, if appropriate.

Finally, either one of us can revoke permission to use the e-mail system at any time.
I DO want to communicate with my therapist electronically. I have read the above information and understand the limitations of security on information transmitted. I understand that my doctor may not be able to communicate with me electronically about my specific condition if I live outside of the state in which my doctor is licensed.

PATIENT:

I understand that my medical professionals will bill my insurance if it is present.My benefits have been explained to me and I understand that there may be some out-of-pocket expenses in the form of co-pays, co-insurance, and deductibles.

I understand that unpaid expenses will be my responsibility and are due as known at time of service and after the insurance remits.
I understand cancellations are to be 1 day for every hour of scheduling. If sessions are 2 hours, 2 days are expected cancellation before a visit. A $25 cancellation fee will result when the cancellation policy is not adhered to. In cases of illness, please know that much of our work can be done on patients suffering from minor ailments such as colds, flu, gastrointestinal issues, etc. and our work will be beneficial in helping you recover from these ailments. I understand I will be reimbursed for any overages I have paid that my insurance reimburses.