First Name *

Last Name *

Date of birth

Phone *

Email *

Area of Concern, List all that apply

Which body part would you like addressed today?

Consents and Agreements

I understand that I will be participating in wellness today, incorporating traditional techniques. I have been instructed by the physical therapist to ask as many questions as I need to increase my comfort and understanding of my wellness visit. I will discuss any concerns and/or hesitations that I may have with my physical therapist throughout my session, as these could affect my comfort and security during the process. By signing at the end of this form, I am giving my consent to participate ("informed consent”). I understand that by signing this form, I release this physical therapist of all liabilities for my health and safety during my participation in this process *

I understand and consent to the wellness services as stated above

I do NOT consent to a wellness visit today

Dry Needling: My signature below represents my consent to the performance of dry needling and my consent to any measures necessary to correct complications, which may result. I am aware I can withdraw my consent at any time. I understand that I will inform the therapist of any precautions. I understand it is my obligation to inform the therapist if yes to any of the below questions *

I am currently taking blood thinners

I am pregnant or could potentially be pregnant

I have a known metal allergy

None of the above conditions

By participating in this event I authorize Achieve Movement Physical Therapy & Sports Rehab to use my face and voice online (social media platforms, YouTube and website). By submitting this form, I hereby conent to the use of photos/videos by AMPT

Event treatment and consent agreement *

I agree

Signature *

Clear

By signing my e-signature above, I verify that I have read and agreed to all of the information contained in this consent form and that the information I have provided is true and accurate.

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.