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
If you fail to give 24 hours notice, you will be charged a $125 late cancellation fee. There are no exceptions to this policy. We require a credit card on file for all patients and clients. We cannot accept patients for treatment that are more than 15 minutes late. After 15 minutes, the appointment will be considered a late cancellation and the $125 fee will be charged.
