____    I hereby consent, by my own free will, to voluntarily engage in the virtual/ tele-health session, through telephone or video conferencing with HIPAA compliant doxy.me (or any other suitable video platform during the Shelter in Place orders in good faith).  

___.     I understand that I am 100% responsible for payment of this session, due at the time of scheduling. Established clients who do not prepay, are required to pay during the session.    

___.    If I am not in the secure waiting room within 8 minutes of my appointment's start time, I am considered a no-show and owe the full session rate.
                                                                                                                                                   
____    I hereby consent to the evaluation and treatment of my condition by a licensed physical therapist (Liz Duncanson PT with Body Temple Physical Therapy Inc.). I understand that the physical therapist will explain the nature and purposes of these procedures, evaluation, and course of treatment. 


____    I understand that recommendations will be made by my therapist, based on the findings in this session, for improvement of my pain and overall wellness. I understand that I may be directed through specific activities, exercises and/ or movements as instructed by my therapist.  I am aware that my physical therapist will inform me of expected benefits and complications, and any discomforts, and risk that may arise, as well as alternatives to the proposed treatment and the risk and consequences of no treatment.                

____    I have been informed and understand that during my participation in any sessions, I will be responsible for honestly reporting any symptoms I may have, such as pain, fatigue, shortness of breath, pain or ANY other findings. 


____    I know that it is my right to stop any activity at any time, during any session, as well as it being my obligation to inform the therapist of any symptoms, should any develop (as indicated above).


____    I understand that my therapist will make every effort to address my symptoms, functional deficits (if any) and concerns and that the goal is for total alleviation of symptoms and/ or improvement of function. Even with the best program there is a possibility that I may not notice changes or improvements. 


____    I recognize that these sessions will allow me to learn ways to move better, feel better and teach me techniques and skills that I can utilize independently on a daily basis and improve my quality of life. 


____    I am aware that addressing my symptoms or diagnosis may take a few sessions and I am required to closely follow all provided instruction to ensure improvements. 


____    I understand that the number of sessions will vary based on the primary complaints and symptoms.

____    NO insurance in any form will be billed, charged or collected for these sessions.  I choose by my own free will to participate and invest in this service.


____    In taking part in these sessions, via phone or video platform, I acknowledge that I am fully responsible for any and all risks, injuries, or damages, known or unknown, which might occur as a result of my participation.                
By signing below, I hereby WAIVE AND RELEASE Body Temple PT Inc., its owners, officers, employees, and instructors from any claim, demand, cause of action of any kind resulting from or related to my participation in the online/ telehealth sessions.

TO GRANT BODY TEMPLE PT AND LIZ DUNCANSON PT CONSENT
PLEASE ENTER YOUR NAME, EMAIL ADDRESS, AND CLICK "I AGREE" BELOW: