CONSENT TO EVALUATE AND TREAT
I hereby request and consent to the performance of various modes of physical therapy on me (or the patient named below, for who I am legally responsible) by Bondurant Physical Therapy and Sports Medicine and/or other licensed physical therapists working at the clinic. I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from the treatments. I intend this consent form to cover the entire course of treatment of my present condition and for any future condition(s) for which I seek treatment. I understand that I may refuse treatment at any time and that I am responsible for my healthcare choices.
The office of Bondurant Physical Therapy and Sports Medicine is committed to upholding the security and confidentiality of personal information that you provide to us. We take responsibility of safeguarding your information very seriously. We do not share or sell patient information with anyone outside our office without your written consent. This policy covers information including personal, financial, or health information about a consumer or customer relationship.