Consent to Treat / Privacy Policy

  • Consent: I give permission to VASTA Physical Therapy to provide medical treatment to me as determined to be appropriate and necessary by my treating therapist. I recognize that the practice of physical therapy is as much an art as a science, and therefore acknowledge that no guaranties have been or can be made regarding the likelihood of success or outcome of any therapy. I also understand that physical therapy care may involve the touching of my body by my therapist or other members of the clinic's professional staff and that full or partial disrobing may be required to facilitate such care, all of which is expressly consented to by me. I understand that I have the option to have a second person present in the exam room for my evaluation and treatment sessions. I understand that it is my responsibility to bring this person and that VASTA Physical Therapy, Inc. may not have staff available to provide this person. I have been cleared by my medical physician to participate in strenuous exercise. I recognize that it is my responsibility to discuss any precautions or contraindications to my participation in any exercise program with my therapist. Participation in any form of exercise carries some risk for injury and I accept these inherent risks. I recognize that in order to best treat my condition, my therapist may utilize treatment techniques that carry some small risk of injury. The risks of Manual Therapy and Trigger Point Dry Needling are summarized below.
  • Manual Therapy: A minority of patients may notice stiffness or soreness after the first few days of treatment. I understand that the risk of more severe complications due to joint manipulation have been described as “rare”, estimates of incidence are widely variable and range from 1 in 50,000 to as low as 1 in 5 million manipulations. These risk are further reduced through the modification of techniques and the use of screening procedures utilized by VASTA PT clinicians. With this consideration, I understand and am informed that, as in the practice of medicine, in the practice of manual therapy there are some risks to treatment, including but not limited to strains and sprains, exacerbation of symptoms, dislocations, fractures, disc injuries or strokes. Trigger Point Dry Needling: The procedure of Trigger Point Dry Needling (TDN) involves piercing the skin in order to introduce a thin filament into the effected muscle for therapeutic purposes. In general, this technique has been well studied and is reported in the literature as “a very safe treatment” technique. The risks for this treatment are minimal and include a local infection or mild bruising at the needling site. VASTA therapists utilize clean techniques to minimize this risk. Additionally, the literature describes a very low risk (<1 in 5,000) of pneumothorax (a partially collapsed lung) rarely necessitating intervention. Safe techniques around the upper trunk greatly minimize this risk.
  • Privacy: I have read and fully understand VASTA Physical Therapy Inc.’s Notice of Information Practices. I understand that my personal health information may be used or disclosed for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed if I notify the practice. I acknowledge that I have been given the opportunity to read and receive a copy of the Notice of Privacy Practices. This assignment will remain in effect until revoked by me in writing and a photocopy of this assignment is to be considered as valid as the original. I allow VASTA Physical Therapy, Inc. to provide information to any third party payors or those hired by the third party payors which may be partially or wholly responsible for payment of my physical therapy bill. I allow VASTA Physical Therapy, Inc. to release information to BMS Practice Solutions on my behalf for billing purposes. I also allow VASTA Physical Therapy to release my information to the provider or office of provider from which I was referred, or to those offices I request.
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