I recognize that I am suffering from a condition requiring physical therapy services and treatment. I hereby consent to the rendering of physical therapy services by Wolf Physical Therapy (WPT), as described to me or as my physician or WPT determines are necessary. I understand that the practice of physical therapy is not an exact science and that physical therapy treatment involves risk of injury. I acknowledge that no guarantees have been made to me about the outcome of treatment. I voluntarily request the right to participate in WPT's physical therapy program. I do hereby discharge, release, and hold harmless WPT and any of it's personnel participating in this rehabilitation program from any and all liability for damage of any kind or character resulting from any injury or condition that I may suffer, or may result from such a rehabilitation program.

Dry Needling is not acupuncture but uses acupuncture needles to effect a change in myofascial restrictions. Myofascial trigger points and tender points that appear in soft tissues, and are painful sites, reflect abnormal nervous system activity associated with many neuro-musculoskeletal conditions that are treated. The procedure known as Dry Needling is an important tool for diagnosing, treating, and monitoring changes in myofascial trigger/tender points. During the procedure, a sterile, very thin, solid filament needle is inserted into tissue that may be associated with one or a number of your complaints. The number of needles and the frequency of the procedure will depend entirely on your condition at each office visit. There may be some discomfort and little to no bleeding with tthis procedure. While an infection is an unlikely event with this procedure, whenever there is penetration of the skin, there is a risk of infection. Other unlikely but possible events include fainting, soreness, pneumothorax (lung puncture). By initialing at the end of this paragraph you acknowledge understanding these risks and disclose if you have a fear of needles, a genetic bleeding disorder, a history of a blood disorder that can be transmitted to another person, are regularly taking any blood thinning medication (for example, Coumadin or Warfarin), or are regularly taking any pain relievers containing ibuprofen, NSAIDS, aspirin or acetaminophen (for example, Tylenol, Advil, Aleve, or Bufferin). Please inform your physical therapist.

I hereby give consent to WPT to use and disclose my protected health information for the purposes of treatment, payment, and health care operations. You may cancel this consent at any time. Your cancellation must be in writing, signed by you or on your behalf, and delivered in person or by mail, but will only be effective when actually received. Your cancellation will not be effective to the extent that others or we have acted in reliance upon this consent. You have the right to request restriction on the usage and disclosure of your protected health information for the purposes of treatment, payment, or health care operations.

I understand that I am financially responsible for all charges. Any insurance reimbursement information quoted by WPT is just an estimate, and may be different from what is received. I understand that I am responsible for all charges, even those not reimbursed from my insurance.

I hereby agree to supply 24 hours notice for any and all cancelled appointments. I agree that if 24 hours notice is not given to WPT for any cancellations I may be assessed a $20 cancellation fee.

I understand that by clicking submit below, I am stating that I have read the above terms and conditions and agree to them. By typing your full name and date, you are agreeing to sign this document with the full legal representation of your written signature.