Road to Dawn Strength and Wellness

516-924-6062
[email protected]
https://roadtodawnwellness.com/home-9451

Physical Therapy Liability Waiver and Consent to Treat Form

I, the patient hereby consent to undergo physical therapy treatment at ROAD TO DAWN STRENGTH AND WELLNESS under the care of Dr. Nick Cartaya, PT, DPT. I understand and agree to the following terms and conditions:

Risks and Benefits: I acknowledge that physical therapy treatment, including but not limited to manual therapy, exercises, and modalities, carries certain risks and benefits. I understand that while every effort will be made to ensure my safety during treatment, unforeseen complications may arise.

Dry Needling: I understand that dry needling is a technique used in physical therapy for the treatment of muscle pain and dysfunction. This procedure involves the insertion of thin, solid needles into trigger points or muscle knots. I acknowledge that while dry needling is generally considered safe, there are potential risks and side effects, including but not limited to:

Soreness or bruising at the needle insertion site, bleeding or bruising at the insertion site, nerve injury or damage, pneumothorax (rare but serious complication when needling near the chest) and/or possibly allergic reaction to the needles. Your physical therapist may consider dry needling in the plan of care if deemed appropriate.

Assumption of Risk: I understand that undergoing physical therapy treatment, including dry needling, involves certain risks, known and unknown. I voluntarily assume all risks associated with the treatment, including the risk of personal injury. Release of Liability: In consideration of receiving physical therapy treatment, I hereby release, waive, and discharge ROAD TO DAWN STRENGTH AND WELLNESS its employees, agents, and affiliates from any and all claims, liabilities, or damages arising out of or in connection with the treatment provided, including but not limited to those resulting from negligence or malpractice.

Emergency Medical Treatment: In the event of a medical emergency, I authorize ROAD TO DAWN STRENGTH AND WELLNESS, and its staff to seek and administer necessary medical treatment, including hospitalization, anesthesia, surgery, or other medical procedures deemed necessary for my well-being.

Consent to Treatment: I consent to receive physical therapy treatment as recommended by my therapist, including any necessary adjustments to my treatment plan based on my progress and response to therapy.

Confidentiality: I understand that my personal and medical information will be kept confidential in accordance with HIPAA regulations, except as required by law.

I have read and understand the above information. By agreeing to become a patient and scheduling a visit by completing the "REQUEST APPOINTMENT FORM" above, I acknowledge that I am voluntarily consenting to physical therapy treatment and assuming any associated risks.