Release of Information & Consent for Treatment. All information provided herein is true and correct. I wish to receive treatment at Progressive Physiotherapy Clinic. I permit its employees and all other persons caring for me to treat me in ways they judge are beneficial to me.I consent to rehabilitation and related services at Facility. I understand, acknowledge and affirm that such rehabilitation and related services may involve bodily contact, touching and/or direct contact of a sensitive nature. I understand that this care can include an evaluation, testing and treatment. No guarantees have been made to me about the outcome of this care. I give permission to Progressive Physiotherapy Clinic to release information, verbal and written, contained in my medical record, and other related information, to my insurance company, rehab nurse, case manager, attorney, employer, school, related healthcare provider, assignees and/or beneficiaries and all other related persons as it relates to my treatment and/or payment for services provided. I authorize Progressive Physiotherapy Clinic to obtain medical records and/or professional information from my physician or other medical professional as it relates to my treatment.
I hereby acknowledge that the information I provided on the Intake Form and the Patient Data Sheet is correct
