Empower PT 2021 Client Information and Policies Update

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Valued Empower PT client with the new year we are moving forward to enforce some new and improved company policies to ensure proper safety and efficiency for all clients and staff members.

Please take the time to read the below statements and make the proper acknowledgements to recognize your agreement to all new policies.

We ask that you please complete this form by Monday, February 22nd, 2021. Thank you for taking the time to better improve your experience and investment into Empower PT.

If you have any questions or concerns please email us at admin@empowertampa.com or call us at (813) 508-2553.

First and Last Name *

Date of Birth *

YYYY

Street Address *

Address City/State/Zip *

Phone Number *

Emergency Contact Name *

Emergency Contact Relationship to Patient *

Emergency Contact Phone Number *

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