Revised January 2021
PATIENT INFORMATION AND CONSENT FORM
CONSENT FOR CARE AND TREATMENT: I hereby agree and give my consent to Foothills Sports Medicine Physical
Therapy to furnish appropriate rehabilitative care and treatment, as considered necessary and in the best interest in order
to attend to the physical condition. I understand that the benefits and risks to all interventions will be explained and that
the patient holds the final judgment in such matters.
If under 18, Parent/Guardian: _______________________________________________________________________
Relationship to Patient: ______________________________ Parent/Guardian Date of Birth: ______________________
MEMBER DIRECT PAYMENT NOTIFICATION: Arizona state constitution permits you to pay a healthcare provider for
health care services directly. If you have any active health insurance coverage, please review the provider’s policies
regarding payment before you make any arrangements to pay directly. By signing below, I agree to have my physical
therapy claims submitted to the medical insurance carrier that I have supplied.
AUTHORIZATION TO PAY: I hereby authorize insurance payment directly to Foothills Sports Medicine Physical Therapy,
Billing Department, 15410 S. Mountain Pkwy. Suite 112, Phoenix, AZ 85044 for medical services rendered. I understand
that I am financially responsible for the charges not covered by my insurance. In the event of default, I promise to pay
collection costs and reasonable fees as may be required to obtain collection of this account.
ATTENDANCE AGREEMENT: Due to the nature of physical therapy, your progress and full recovery are dependent on
both our experienced physical therapists, and your active participation and commitment to your appointments. If you need
to cancel your appointment, please contact Foothills Sports Medicine at least one day prior to your appointment. If you call
to cancel your appointment on the same day as your appointment or if you do not show, a $25.00 cancellation fee will be
WORKERS’ COMPENSATION PATIENTS: We are required to inform your Workers’ Compensation Adjuster and/or
Rehabilitation Manager of all missed or canceled appointments. It is also required that all missed visits be rescheduled.
PHOTOGRAPHY/VIDEOGRAPHY AGREEMENT: I understand that in order to protect the confidentiality of our patients,
there can be no filming, going “live” via social media or taking pictures of my treatment, or that of other patients, without
prior authorization from the Clinic Director.
AUTHORIZATION TO COMMUNICATE ELECTRONICALLY: I understand that authorized personnel (including my
physical therapist) from Foothills Sports Medicine Physical Therapy may communicate with me regarding scheduling/
appointments, the treatment provided, home exercise programs, and educational/informative content as it relates to my
condition. I understand that my protected health information (PHI) will not be communicated electronically. I understand
that I have the opportunity to opt-out of future communications at any time using the “unsubscribe” option on any
communication via text or email
Would you like to receive appointment reminders: Text Message Email
By my signature below, I certify that I have read, understand, and fully agree to each of the statements in this document:
Printed Name: __________________________________________________________ Date: _____________________
Patient/Guardian Signature: ________________________________________________ Date: _____________________