Medical History Hi there. We’ve got some important questions. Step 1 of 9 11% Name* First Last Age*Gender* Male Female Non-binary Occupation* How did you hear of us?* Yelp! Google Facebook Instagram My Doctor Trainer Pilates Instructor Massage Therapist Other Your Doctors NameSo we can send them a Thank You! Name of your TrainerSo we can send them a Thank You! Name of your Pilates InstructorSo we can send them a Thank You! Name of your Massage TherapistSo we can send them a Thank You! OtherSo we can send them a Thank You! Please provide a brief explanation about why you are seeking physical therapy:*What body part best describes the area you are seeking physical therapy for?* Head, Neck and/or Upper Shoulder Shoulder, Elbow and/or Hand Upper and/or Lower back Hip, Knee, Ankle and/or Foot Pain Scale*0 is least pain - 10 is most pain 0 1 2 3 4 5 6 7 8 9 10 What are your goals for Physical Therapy?*Are you CURRENTLY or RECENTLY taking any medications? (leave blank if 'No')If yes, please list all medications. Do you have an IMMEDIATE FAMILY history of any of the following?* Cancer High blood pressure Diabetes Early onset osteoporosis Heart problems Blood clots None Other OtherEnter other here Please select your Therapist:* Dr. Paul Ochoa Dr. Monique Dupree Neck Index This questionnaire will give your provider information about how your neck condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem.Pain Intensity* Does Not Apply I have no pain at the moment. The pain is very mild at the moment. The pain comes and goes and is moderate. The pain is fairly severe at the moment. The pain is very severe at the moment. The pain is the worst imaginable at the moment. Personal Care* Does Not Apply I can look after myself normally without causing extra pain. I can look after myself normally but it causes extra pain. It is painful to look after myself and I am slow and careful. I need some help but I manage most of my personal care. I need help every day in most aspects of self care. I do not get dressed, I wash with difficulty and stay in bed. Sleeping* Does Not Apply I have no trouble sleeping. My sleep is slightly disturbed (less than 1 hour sleepless). My sleep is mildly disturbed (1-2 hours sleepless). My sleep is moderately disturbed (2-3 hours sleepless). My sleep is greatly disturbed (3-5 hours sleepless). My sleep is completely disturbed (5-7 hours sleepless). Lifting* Does Not Apply I can lift heavy weights without extra pain. I can lift heavy weights but it causes extra pain. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (e.g., on a table). Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned. I can only lift very light weights. I cannot lift or carry anything at all. Reading* Does Not Apply I can read as much as I want with no neck pain. I can read as much as I want with slight neck pain. I can read as much as I want with moderate neck pain. I cannot read as much as I want because of moderate neck pain. I can hardly read at all because of severe neck pain. I cannot read at all because of neck pain. Driving* Does Not Apply I can drive my car without any neck pain. I can drive my car as long as I want with slight neck pain. I can drive my car as long as I want with moderate neck pain. I cannot drive my car as long as I want because of moderate neck pain. I can hardly drive at all because of severe neck pain. I cannot drive my car at all because of neck pain. Concentration* Does Not Apply I can concentrate fully when I want with no difficulty. I can concentrate fully when I want with slight difficulty. I have a fair degree of difficulty concentrating when I want. I have a lot of difficulty concentrating when I want. I have a great deal of difficulty concentrating when I want. I cannot concentrate at all. Recreation* Does Not Apply I am able to engage in all my recreation activities without neck pain. I am able to engage in all my usual recreation activities with some neck pain. I am able to engage in most but not all my usual recreation activities because of neck pain. I am only able to engage in a few of my usual recreation activities because of neck pain. I can hardly do any recreation activities because of neck pain. I cannot do any recreation activities at all. Work* Does Not Apply I can do as much work as I want. I can only do my usual work but no more. I can only do most of my usual work but no more. I cannot do my usual work. I can hardly do any work at all. I cannot do any work at all. Headaches* Does Not Apply I have no headaches at all. I have slight headaches which come infrequently. I have moderate headaches which come infrequently. I have moderate headaches which come frequently. I have severe headaches which come frequently. I have headaches almost all the time. Pain Intensity Hidden NumberPersonal Care Hidden NumberSleeping Hidden NumberLifting Hidden NumberReading Hidden NumberDriving Hidden NumberConcentration Hidden NumberRecreation Hidden NumberWork Hidden NumberHeadaches Hidden NumberNeck Index TotalIndex Score = [Sum of all statements selected / (# of sections with a statement selected x 5)] x 100Over the last 2 weeks, how often have you been bothered by the following problems?Little interest or pleasure in doing things* Not at all Several Days More than half days Nearly every day Feeling down, depressed or hopeless* Not at all Several Days More than half days Nearly every day HiddenPHQ 2 Score DASH Score - Disabilities of the Arm, Shoulder and Hand Please rate your ability to do the following activities in the last week by checking the number beside the appropriate response. 1. Open a tight or new jar.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 12. Write.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 23. Turn a key.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 34. Prepare a meal.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 45. Push open a heavy door.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 56. Place an object on a shelf above your head.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 67. Do heavy household chores (e.g., wash walls, wash floors).* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 78. Garden or do yard work.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 89. Make a bed.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 910. Carry a shopping bag or briefcase.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 1011. Carry a heavy object (over 10 lbs).* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 1112. Change a lightbulb overhead.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 1213. Wash or blow dry your hair.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 1314. Wash your back.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 1415. Put on a pullover sweater.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 1516. Use a knife to cut food.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 1617. Recreational activities which require little effort (e.g., cardplaying, knitting, etc.).* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 1718. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.).* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 1819. Recreational activities in which you move your arm freely (e.g., playing frisbee, badminton, etc.).* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 1920. Manage transportation needs (getting from one place to another).* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 2021. Sexual activities.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 2122. During the past week, to what extent has your arm, shoulder or hand problem interfered with your normal social activities with family, friends, neighbours or groups? (circle number)* Not At All Slightly Moderately Quite A Bit Extremely Does Not Apply Number 2223. During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder or hand problem?* Not Limited At All Slightly Limited Moderately Limited Very Limited Unable Does Not Apply Number 23Please rate the severity of the following 5 symptoms in the last week. (# 24 thru # 28 )24. Arm, shoulder or hand pain.* None Mild Moderate Severe Extreme Does Not Apply Number 2425. Arm, shoulder or hand pain when you performed any specific activity.* None Mild Moderate Severe Extreme Does Not Apply Number 2526. Tingling (pins and needles) in your arm, shoulder or hand.* None Mild Moderate Severe Extreme Does Not Apply Number 2627. Weakness in your arm, shoulder or hand.* None Mild Moderate Severe Extreme Does Not Apply Number 2728. Stiffness in your arm, shoulder or hand.* None Mild Moderate Severe Extreme Does Not Apply Number 2829. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty So Much Difficulty That I Can't Sleep Does Not Apply Number 2930. I feel less capable, less confident or less useful because of my arm, shoulder or hand problem.* Strongly Disagree Disagree Neither Agree Or Disagree Agree Strongly Agree Does Not Apply Number 30DASH Score( [(sum of n responses / n) - 1] x 25, where n is the number of completed responses.)Over the last 2 weeks, how often have you been bothered by the following problems?Little interest or pleasure in doing things* Not at all Several Days More than half days Nearly every day Feeling down, depressed or hopeless* Not at all Several Days More than half days Nearly every day HiddenPHQ 2 Score Back Index This questionnaire will give your provider information about how your back condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem.Pain Intensity* Does Not Apply The pain comes and goes and is very mild. The pain is mild and does not vary much. The pain comes and goes and is moderate. The pain is moderate and does not vary much. The pain comes and goes and is very severe. The pain is very severe and does not vary much. Personal Care* Does Not Apply I do not have to change my way of washing or dressing in order to avoid pain. I do not normally change my way of washing or dressing even though it causes some pain. Washing and dressing increases the pain but I manage not to change my way of doing it. Washing and dressing increases the pain and I find it necessary to change my way of doing it. Because of the pain I am unable to do some washing and dressing without help. Because of the pain I am unable to do any washing and dressing without help. Sleeping* Does Not Apply I get no pain in bed. I get pain in bed but it does not prevent me from sleeping well. Because of pain my normal sleep is reduced by less than 25%. Because of pain my normal sleep is reduced by less than 50%. Because of pain my normal sleep is reduced by less than 75%. Pain prevents me from sleeping at all. Lifting* Does Not Apply I can lift heavy weights without extra pain. I can lift heavy weights but it causes extra pain. Pain prevents me from lifting heavy weights off the floor. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (e.g., on a table). Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned. I can only lift very light weights. Sitting* Does Not Apply I can sit in any chair as long as I like. I can only sit in my favorite chair as long as I like. Pain prevents me from sitting more than 1 hour. Pain prevents me from sitting more than 1/2 hour. Pain prevents me from sitting more than 10 minutes. I avoid sitting because it increases pain immediately. Traveling* Does Not Apply I get no pain while traveling. I get some pain while traveling but none of my usual forms of travel make it worse. I get extra pain while traveling but it does not cause me to seek alternate forms of travel. I get extra pain while traveling which causes me to seek alternate forms of travel. Pain restricts all forms of travel except that done while lying down. Pain restricts all forms of travel. Standing* Does Not Apply I can stand as long as I want without pain. I have some pain while standing but it does not increase with time. I cannot stand for longer than 1 hour without increasing pain. I cannot stand for longer than 1/2 hour without increasing pain. I cannot stand for longer than 10 minutes without increasing pain. I avoid standing because it increases pain immediately. Social Life* Does Not Apply My social life is normal and gives me no extra pain. My social life is normal but increases the degree of pain. Pain has no significant affect on my social life apart from limiting my more energetic interests (e.g., dancing, etc). Pain has restricted my social life and I do not go out very often. Pain has restricted my social life to my home. I have hardly any social life because of the pain. Walking* Does Not Apply I have no pain while walking. I have some pain while walking but it doesn’t increase with distance. I cannot walk more than 1 mile without increasing pain. I cannot walk more than 1/2 mile without increasing pain. I cannot walk more than 1/4 mile without increasing pain. I cannot walk at all without increasing pain. Changing Degree of Pain* Does Not Apply My pain is rapidly getting better. My pain fluctuates but overall is definitely getting better. My pain seems to be getting better but improvement is slow. My pain is neither getting better or worse. My pain is gradually worsening. My pain is rapidly worsening. Pain Intensity NumberPersonal Care NumberSleeping NumberLifting NumberSitting NumberTraveling NumberStanding NumberSocial Life NumberWalking NumberChanging Degree of Pain NumberBack Index NumberIndex Score = [Sum of all statements selected / (# of sections with a statement selected x 5)] x 100Over the last 2 weeks, how often have you been bothered by the following problems?Little interest or pleasure in doing things* Not at all Several Days More than half days Nearly every day Feeling down, depressed or hopeless* Not at all Several Days More than half days Nearly every day HiddenPHQ 2 Score Lower Extremity Functional Scale We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your lower limb problem for which you are currently seeking attention. Please provide an answer for each activity. Today, do you or would you have any difficulty at all with:Any of your usual work, housework, or school activities.* Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty Your usual hobbies, recreational or sporting activities.* Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty Getting into or out of the bath.* Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty Walking between rooms.* Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty Putting on your shoes or socks.* Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty Squatting.* Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty Lifting an object, like a bag of groceries from the floor.* Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty Performing light activities around your home.* Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty Performing heavy activities around your home.* Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty Getting into or out of a car.* Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty Walking 2 blocks.* Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty Walking a mile.* Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty Going up or down 10 stairs (about 1 flight of stairs).* Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty Standing for 1 hour.* Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty Sitting for 1 hour.* Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty Running on even ground.* Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty Running on uneven ground.* Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty Making sharp turns while running fast.* Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty Hopping.* Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty Rolling over in bed.* Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty LEFS NumberSCORE: _____/ 80Over the last 2 weeks, how often have you been bothered by the following problems?Little interest or pleasure in doing things* Not at all Several Days More than half days Nearly every day Feeling down, depressed or hopeless* Not at all Several Days More than half days Nearly every day HiddenPHQ 2 Score F2PT Demographics FormBilling Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code ** If applying for donation based sessions due to COVID 19 unemployment, please let us know how much you would like to donate for your session Email*Your email will be your account username. Enter Email Confirm Email Password*This is your account password. Enter Password Confirm Password Phone*Date of Birth* MM slash DD slash YYYY Emergency Contact Name Relationship to you? Emergency Contact phone number Insurance InformationPrimary Insurance Company Member ID Secondary Insurance Company (If Applicable) Member ID Patient Responsibilities- I request that payment of benefits be made on my behalf to F Squared Physical Therapy for any services rendered. -I understand and acknowledge that submission of claims is not a guarantee of payment. If for any reason my carrier does not cover and/or all of my physical therapy treatments, I agree that I am responsible for the payment of the entire amount. -I understand that it is my responsibility to obtain a new prescription at the end of the specified time period. If I fail to obtain an updated prescription, I understand that I will be responsible for payment of services not covered by my carrier. -I understand that it is my responsibility to make sure that my bills are paid in a reasonable time (no longer than 1 month from the date of treatment). If for any reason any portion of my bill is not paid, I understand that I am financially responsible for charges for services rendered. -I understand and agree that if my carrier makes any payments directly to me for services rendered, i will remit the same payment to F Squared Physical Therapy. -I understand that it is my responsibility to notify F Squared Physical Therapy of any changes to my insurance carrier or coverage as soon as possible. Any failure to report such changes will result in the patient being financially responsible for any lapse in coverage or authorization. -I herby authorize F Squared Physical Therapy to release all information necessary to secure payment of benefits. I authorize the use of this signature on all insurance submissions. -I understand it is my responsibility for submitting and following through for reimbursement through my insurance for services rendered by F Squared Physical Therapy when paying for service out of pocket. F Squared Physical Therapy is not held responsible for insurance reimbursement in this situation.HiddenPatient Responsibilities- I request that payment of benefits be made on my behalf to F Squared Physical Therapy for any services rendered. -I understand and acknowledge that submission of claims is not a guarantee of payment. If for any reason my carrier does not cover and/or all of my physical therapy treatments, I agree that I am responsible for the payment of the entire amount. -I understand that it is my responsibility to obtain a new prescription at the end of the specified time period. If I fail to obtain an updated prescription, I understand that I will be responsible for payment of services not covered by my carrier. -I understand that it is my responsibility to make sure that my bills are paid in a reasonable time (no longer than 1 month from the date of treatment). If for any reason any portion of my bill is not paid, I understand that I am financially responsible for charges for services rendered. -I understand and agree that if my carrier makes any payments directly to me for services rendered, i will remit the same payment to F Squared Physical Therapy. -I understand that it is my responsibility to notify F Squared Physical Therapy of any changes to my insurance carrier or coverage as soon as possible. Any failure to report such changes will result in the patient being financially responsible for any lapse in coverage or authorization. -I herby authorize F Squared Physical Therapy to release all information necessary to secure payment of benefits. I authorize the use of this signature on all insurance submissions. -I understand it is my responsibility for submitting and following through for reimbursement through my insurance for services rendered by F Squared Physical Therapy when paying for service out of pocket. F Squared Physical Therapy is not held responsible for insurance reimbursement in this situation.Waiver of LiabilityIn agreeing to receive care provided by F Squared Physical Therapy and to use the facilities provided therefore by F Squared Physical Therapy located at 250 West 26th Street Suite 402, New York, New York, 10001 I agree as follows: I fully understand and acknowledge that (a) the activities in which I will engage as part of the treatment provided by F Squared Physical Therapy and the physical therapy activities and equipment I may use as a part of that treatment have inherent risks, dangers, and hazards and such exists in my use of any equipment and my participation in these activities; (b) my participation in such activities and/or use of such equipment may result in injury or illness including, but not limited to bodily injury, disease, strains, fractures, partial and/or total paralysis, death or other ailments that, could cause serious disability; (c) these risks and dangers may be caused by the negligence of the representatives or employees of F Squared Physical Therapy, the negligence of the participants, the negligence of others, accidents, breaches of contract, or other causes. By my participation in these activities and for use of equipment, I hereby assume all risks and dangers and all responsibility for any losses and/or damages whether caused in whole or in part by the negligence or the conduct of the representatives or employees of F Squared Physical Therapy, or by any other person. I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify F Squared Physical Therapy their representatives, employees, and assigns from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my use of any equipment or participation in these activities. I specifically understand that I am releasing, discharging, and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the representatives or employees of F Squared Physical Therapy. HiddenWaiver of LiabilityIn agreeing to receive care provided by F Squared Physical Therapy and to use the facilities provided therefore by F Squared Physical Therapy located at 250 West 26th Street Suite 402, New York, New York, 10001 I agree as follows: I fully understand and acknowledge that (a) the activities in which I will engage as part of the treatment provided by F Squared Physical Therapy and the physical therapy activities and equipment I may use as a part of that treatment have inherent risks, dangers, and hazards and such exists in my use of any equipment and my participation in these activities; (b) my participation in such activities and/or use of such equipment may result in injury or illness including, but not limited to bodily injury, disease, strains, fractures, partial and/or total paralysis, death or other ailments that, could cause serious disability; (c) these risks and dangers may be caused by the negligence of the representatives or employees of F Squared Physical Therapy, the negligence of the participants, the negligence of others, accidents, breaches of contract, or other causes. By my participation in these activities and for use of equipment, I hereby assume all risks and dangers and all responsibility for any losses and/or damages whether caused in whole or in part by the negligence or the conduct of the representatives or employees of F Squared Physical Therapy, or by any other person. I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify F Squared Physical Therapy their representatives, employees, and assigns from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my use of any equipment or participation in these activities. I specifically understand that I am releasing, discharging, and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the representatives or employees of F Squared Physical Therapy. Cancellation Policy-I acknowledge there is a 24-hour Cancellation Policy and understand that if I do not cancel 24 hours before my scheduled appointment, I accept the responsibility of being charged $100.00. -I understand arriving later then 20 minute after my scheduled appointment time is considered a "no-show" and I will be charged $100.00. -I understand that I will not be seen if I arrive later then 20 minutes after my scheduled appointment. -I understand that I am responsible for my deductible, co-payments, and all late cancellation or no-show fees if applicable. -I understand if I "no-show" to 3 consecutive appointments, my scheduled appointments will be cancelled and I will need to call to make future appointments on a "same-day" basis.HiddenCancellation Policy-I acknowledge there is a 24-hour Cancellation Policy and understand that if I do not cancel 24 hours before my scheduled appointment, I accept the responsibility of being charged $100.00. -I understand arriving later then 20 minute after my scheduled appointment time is considered a "no-show" and I will be charged $100.00. -I understand that I will not be seen if I arrive later then 20 minutes after my scheduled appointment. -I understand that I am responsible for my deductible, co-payments, and all late cancellation or no-show fees if applicable. -I understand if I "no-show" to 3 consecutive appointments, my scheduled appointments will be cancelled and I will need to call to make future appointments on a "same-day" basis.Consent For Telemedicine ServicesIntroduction Telemedicine is the delivery of healthcare services when the healthcare provider and patient are not in the same physical location through the use of technology. Providers may include primary care practitioners, specialists, and/or subspecialists. Electronically-transmitted information may be used for diagnosis, therapy, follow-up and/or patient education, and may include any of the following: Patient medical records. Medical images. Interactive audio, video, and/or data communications. Output data from medical devices and sound and video files. The interactive 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. Potential Benefits: Improved access to medical care by enabling a patient to remain in his/her physicians’s office (or at a remote site) while the physician obtains test results and consults with healthcare practitioners at distant/other sites. Obtaining the expertise of a distant specialist. Potential 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: Information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s). The consulting physician(s) are not able to provide medical treatment to the patient through the use of telemedicine equipment nor provide for or arrange for any emergency care that I may require. Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment. Security protocols could fail, causing a breach of privacy of personal medical information. A lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other medical judgment errors. By signing this form, I understand and agree to the following: The laws that protect the privacy and confidentiality of medical information also apply to telemedicine. No information obtained during a telemedicine encounter which identifies me will be disclosed to researchers or other entities without my consent. I have the right to withhold or withdraw my consent to the use of telemedicine during the course of my care at any time. I understand that my withdrawal of consent will not affect any future care or treatment, nor will it subject me to the risk of loss or withdrawal of any health benefits to which I am otherwise entitled. I have the right to inspect all information obtained and recorded during the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee. A variety of alternative methods of medical care may be available to me, and I may choose one or more of these at any time. My physician has explained the alternative care methods to my satisfaction. 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. I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured. My condition may not be cured or improved, and in some cases, may get worse. Patient Consent To The Use of Telemedicine I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care. I hereby consent to and authorize F Squared Physical Therapy to use telemedicine in the course of my diagnosis and treatment. I understand this service may not be a covered benefit under my insurance plan and that I am ultimately responsible for the total cost of the visit. HiddenConsent For Telemedicine Services<p>Introduction</p> <p>Telemedicine is the delivery of healthcare services when the healthcare provider and patient are not in the same physical location through the use of technology. Providers may include primary care practitioners, specialists, and/or subspecialists. Electronically-transmitted information may be used for diagnosis, therapy, follow-up and/or patient education, and may include any of the following:</p> <ul> <li>Patient medical records.</li> <li>Medical images.</li> <li>Interactive audio, video, and/or data communications.</li> <li>Output data from medical devices and sound and video files.</li> </ul> <p>The interactive 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.</p> <p>Potential Benefits:</p> <ol> <li> Improved access to medical care by enabling a patient to remain in his/her physicians’s office (or at a remote site) while the physician obtains test results and consults with healthcare practitioners at distant/other sites.</li> <li> Obtaining the expertise of a distant specialist.</li> </ol> <p>Potential Risks:</p> <p>As with any medical procedure, there are potential risks associated with the use of telemedicine.</p> <p>These risks include, but may not be limited to:</p> <ol> <li> Information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s).</li> <li> The consulting physician(s) are not able to provide medical treatment to the patient through the use of telemedicine equipment nor provide for or arrange for any emergency care that I may require.</li> <li> Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.</li> <li> Security protocols could fail, causing a breach of privacy of personal medical information.</li> <li> A lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other medical judgment errors.</li> </ol> <p>By signing this form, I understand and agree to the following:</p> <ol> <li> The laws that protect the privacy and confidentiality of medical information also apply to telemedicine. No information obtained during a telemedicine encounter which identifies me will be disclosed to researchers or other entities without my consent.</li> <li> I have the right to withhold or withdraw my consent to the use of telemedicine during the course of my care at any time. I understand that my withdrawal of consent will not affect any future care or treatment, nor will it subject me to the risk of loss or withdrawal of any health benefits to which I am otherwise entitled.</li> <li> I have the right to inspect all information obtained and recorded during the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.</li> <li> A variety of alternative methods of medical care may be available to me, and I may choose one or more of these at any time. My physician has explained the alternative care methods to my satisfaction.</li> <li> 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.</li> <li> I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured. My condition may not be cured or improved, and in some cases, may get worse.</li> </ol> <p>Patient Consent To The Use of Telemedicine</p> <p>I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.</p> <p>I hereby consent to and authorize F Squared Physical Therapy to use telemedicine in the course of my diagnosis and treatment.</p> <p>I understand this service may not be a covered benefit under my insurance plan and that I am ultimately responsible for the total cost of the visit.</p> BY MY CLICKING "I AGREE" AND SUBMITTING THIS FORM, I INDICATE THAT I'VE AGREED TO ALL TERMS AND CONDITIONS LISTED ABOVE. I HAVE READ THE ABOVE WAIVER AND RELEASE AND BY SIGNING IT AGREE. IT IS MY INTENTION TO EXEMPT AND RELIEVE F SQUARED PHYSICAL THERAPY FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE OR ANY OTHER CAUSE.* I agree I do not agree Name* First Last Signature* Reset signature Signature locked. Reset to sign again You’re almost done! Once you click on Submit you will be taken to a page where you will need to add a payment method for your co-insurance. 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