Consent Form

  • 1. I do hereby give my consent to the performance by REHAB AT WORK of Physical Therapy, Occupational Therapy and/or Industrial Rehabilitation (hereinafter referred to as "Therapy"). I understand that the Therapy may include, but not limited to: strength, flexibility, pain management, endurance, cardiovascular fitness, coordination, balance, neurological screen, posture, mobility, repetition tolerance, material handling ability, pain questionnaires, and activities of daily living including work tasks. I give my consent voluntarily to participation in Therapy. This consent applies to the entire course of treatment for me at REHAB AT WORK.
  • I understand that there are certain risks associated with the Therapy including, but not limited to: pain, tightness, tenderness, soreness, rashes, burns, slip and fall, dislocation, bone fracture, general discomfort, re-injury and cardiopulmonary signs, such as elevated heart rate, labored breathing, and excessive sweating or light-headedness. I freely and voluntarily assume these risks. I also understand that there are possible benefits associated with the Therapy including greater mobility, recovery, less pain, improved performance level, more function, higher endurance and better ability to perform activities of daily living including work tasks. However, I understand that there is no certainty that I will achieve these benefits and no guarantee has been made to me regarding the outcome of this Therapy.
  • 3. The reasonable alternative(s) to this Therapy and the probable risks and benefits associated with those alternatives have been explained to me, including chiropractic acupuncture, massage, and fitness training.
  • 4. I have been given an opportunity to ask questions and all of my questions have been answered to my satisfaction.
  • 5. I agree to the performance of this Therapy by a licensed staff member at REHAB AT WORK and I understand that he/she will be assisted by other healthcare professionals and such others as he/she considers necessary in my care. I agree to their participation in my care.
  • 6. I take personal responsibility to report or communicate to the therapist any symptoms or concerns that I have as soon as possible. I will take responsibility to follow and conduct myself consistent with the instructions and directions of the therapist including, but not limited to: giving my best effort in participation in the Therapy, performing a home exercise program as instructed and wearing assistive devices as instructed. I understand that I retain the right to decide whether I will continue, modify stop or decline to perform any activity in part or in whole and this will be documented as such.
  • 7. I understand that REHAB AT WORK may use my participation and/or the results of my participation in Therapy as part of research studies or for educational/training purposes. I consent to this as well.
  • 8. I understand that REHAB AT WORK may use my participation and/or the results of my participation in such photographs/videos will be used for identification, evaluation, education and marketing purposes. I understand that this release absolves REHAB AT WORK of all responsibility for any physical, mental or legal consequences herein.
  • 9. I have read the information provided above or it has been read to me. I have been given a copy of this form upon request.
  • Date Format: MM slash DD slash YYYY
  • I, the undersigned, hereby agree to abide by and adhere to these policies. I also agree that in the event of default in the payment of any amount due, if this account is placed in the hands of an agency or attorney for collection or legal action, to pay any additional charges equal to the cost of collection,