Please list name, dosage, frequency, and route if possible.
I consent to rehabilitation and related services at The Cypress Center, A Physical Therapy Corporation. In so doing, I understand, acknowledge and affirm that such rehabilitation and related services may involve bodily contact, touching, and or direct contact of sensitive nature.
I hereby authorize my insurance insurance carrier(s) to pay The Cypress Center, a Physical Therapy Corporation directly for services rendered. I also authorize release of any medical records necessary to facilitate my treatment to process medical claims and as otherwise permitted or required in the Notice of Privacy Practices. I understand fully that in the event my insurance company or financially responsible party does not pay for the services I received, I will be financially responsible for payment.
I understand the risks of unencrypted email and do hereby give permission to The Cypress Center to send me personal health information via unencrypted email and/or patient appointment reminders
I understand that a cancellation must be made at least 24 hours in advance of my scheduled appointment to avoid being charged a $125 cancellation fee.
