I, the undersigned, consent to the evaluation and treatment by the licensed physical therapist(s) of OrthoPrime Physical Therapy, LLC located at 17916 Farmington Road Livonia, MI 48152. I understand that physical therapy involves the assessment and treatment of my physical condition through various modalities, exercises, and techniques.

Nature of Treatment:
I acknowledge that the nature of physical therapy may involve:
❖ Physical examination and assessment
❖ Therapeutic exercises
❖ Manual therapy techniques
❖ Modalities such as heat, cold, ultrasound, and electrical stimulation
❖ Education and advice regarding my condition and rehabilitation
❖ Postural correction, education and exercises

I understand that my participation in treatment is voluntary, and I have the right to withdraw my consent at any time.

Risks and Benefits:
I acknowledge that there are potential risks associated with physical therapy, including but not limited to:
❖ Discomfort or soreness
❖ Aggravation of symptoms
❖ Rare complications

I understand that the benefits of physical therapy may include improvement in function, pain relief, and enhanced quality of life.

Confidentiality:
I understand that my personal health information will be kept confidential and will only be shared with relevant healthcare providers involved in my care, as permitted by law.

 
Financial Responsibility:
I understand that I am responsible for payment of services rendered. I agree to notify the clinic of any changes to my insurance coverage or personal information.

Patient Acknowledgment:
I have read and understand the information provided in this consent form. I have had the opportunity to ask questions regarding my treatment, and all my questions have been answered to my satisfaction.