Touchpoint PT - Evaluation - Patient Information

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TOUCHPOINT PT

Patient Information and Consent

First Name

Last Name

Address

Phone

Date of Birth

Emergency Contact Name

Emergency Contact Phone

Referring Provider

Referring Diagnosis

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

My current location is in one of the following states: Ohio. By law, we are allowed to treat only individuals whose location is in one of the states our PTs are licensed to treat.

I authorize Touchpoint PT and its clinicians to contact me via email and phone for purposes related to my evaluation and treatment. I understand that the therapist may need to follow-up on portions of the evaluation prior to establishing a plan of care.

I hereby agree to the Terms of Service and Privacy Policy, and consent to the evaluation and treatment of my condition via Touchpoint PT's telehealth procedures, including a self-guided recording that will be sent for the purposes of an evaluation by a licensed therapist. I understand the risks of injury that may arise from movements performed during the evaluation as well as any subsequent follow-up treatments.

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.