TOUCHPOINT PT

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TOUCHPOINT PT

Patient Information and Consent

First Name

Last Name

Address

Phone

Date of Birth

Diagnosis / PT Reason

Referring Provider

Emergency Contact Name

Emergency Contact Phone

Choose Evaluation Type

You will be invoiced only after your evaluation has been reviewed. No credit card required.See Pricing

I confirm that I am currently located in the state of Ohio and will inform my physical therapist if my location changes during treatment. I understand that Touchpoint PT is able to only treat patients in states where they are licensed to do so.

I authorize Touchpoint PT and its clinicians to contact me for purposes related to my evaluation and treatment. I understand that this involves the delivery of physical therapy services using electronic communications, information technology, or other means between a physical therapist and a patient who are not in the same physical location.

I understand the potential risks of telehealth, including but not limited to: technical failures, interruptions, unauthorized access, and limitations in the physical therapist's ability to perform hands-on examination and treatment.

I hereby release Touchpoint PT and its employees of any and all liability, claim, damage, or loss of any kind due to my refusal to accept emergency medical services including but not limited to ambulance/urgent care service, physician services, and emergent medical attention.

I hereby understand and agree to the Terms of Service and Privacy Policy and I consent to receive physical therapy services via telehealth.