815 US-10 E Suite 103
Elk River, MN 55330



Intake Form

    Informed Consent for Physical Therapy Services:

    Physical therapy is a patient care service that is provided in order to manage a wide variety of conditions. Services are provided to individuals of all ages regardless of gender, color, ethnicity, creed, national origin, or disability.

    The purpose of physical therapy is to treat disease, injury, and disability by examination,evaluation, diagnosis, prognosis and intervention by use of rehabilitative procedures, mobilization, massage, exercises, and physical agents to aid the patient in achieving their maximum potential within their capabilities and to accelerate convalescence and reduce the length of functional recovery. All procedures will be thoroughly explained to you before you are asked to perform them.

    Response to physical therapy intervention varies from person to person; hence, it is not possible to accurately predict your response to a specific modality, procedure, or exercise protocol. LIft PT, LLC does not guarantee what your reaction will be to a specific treatment, nor does it guarantee that the treatment will help resolve the condition that you are seeking treatment for. Furthermore, there is a possibility that the physical therapy treatment may result in aggravation of existing symptoms and may cause pain or injury.

    It is your right to decline any part of your treatment at any time before or during treatment, should you feel any discomfort or pain or have other unresolved concerns. It is your right to ask your physical therapist about the treatment they have planned based on your individual history, physical therapy diagnosis, symptoms, and examination results. Consequently, it is your right to discuss the potential risks and benefits involved in your treatment.

    Informed Consent of Services Performed by Virtual Physical Therapists:

    Telemedicine involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following: Patient medical records, Medical images, Live two-way audio and video, Output data from medical devices and sound and video files.

    Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

    Expected Benefits:

    • Improved access to medical care by enabling a patient to remain in his/her local healthcare site (i.e. home) while the physical therapist consults at distant/other sites
    • More efficient medical evaluation and management
    • Obtaining expertise of a specialist.

    Possible Risks:

    As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

    • In rare cases, the consultant may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the patient, or at least a rescheduled video consult
    • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment
    • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information
    • In some cases, a person’s condition is not suitable for virtual assessment and treatment.  If so, the therapist will recommend a physician or clinic that is specialized.

    By checking the box associated with “Informed Consent”, You acknowledge that you understand and agree with the following:

    1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities without my written consent.
    2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
    3. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
    4. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
    5. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. The above mentioned people will all maintain confidentiality of the information obtained.