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Consent to Treatment (Physical Therapy) template

A free consent to treatment template for physical therapy, with plain-language treatment, risk, and financial responsibility sections plus a typed signature. Edit the wording with your attorney and send it online.

Consent to Treatment (Physical Therapy)

Consent to treatment

I understand that physical therapy may include evaluation, manual therapy, therapeutic exercise, modalities such as heat, ice, or electrical stimulation, gait and balance training, and education. My therapist has explained the expected benefits, the possible risks (such as temporary soreness), and the alternatives, and I have had the chance to ask questions. I understand that no guarantee has been made about the results of treatment. I may refuse or stop any part of my treatment at any time. I will tell my therapist right away about any change in my health, pain, or medications.

I voluntarily consent to evaluation and treatment by [Practice Name] *

I understand that results are not guaranteed and that I may stop treatment at any time *

Financial responsibility

I am responsible for all charges for services I receive, including any amounts my insurance does not pay. Payment is due at the time of service unless other arrangements are made in writing.

I accept financial responsibility for my care *

Patient details

Patient full name *

Patient date of birth *

Name of person signing, if not the patient

Relationship to patient

Signature

Typing your full legal name below acts as your signature.

Signature — type your full legal name *

Date signed *

What a PT consent form should cover

  1. What treatment may include
  2. Benefits, risks, and alternatives
  3. No guaranteed results
  4. Right to stop treatment
  5. Financial responsibility
  6. Who is signing, if not the patient
  7. Signature and date
What's included
  • I voluntarily consent to evaluation and treatment by [Practice Name]
  • I understand that results are not guaranteed and that I may stop treatment at any time
  • I accept financial responsibility for my care
  • Patient full name
  • Patient date of birth
  • Name of person signing, if not the patient
  • Relationship to patient
  • Signature — type your full legal name
  • Date signed
Prefer paper? Print it

Download this form as a PDF or Word file — free, no account. When you're ready, send the same form as a link so nobody retypes a clipboard.

This template is a starting point, not legal or medical advice, and using it does not by itself make your practice HIPAA compliant. To collect patient health information on TendForm, use the HIPAA plan with a signed Business Associate Agreement, and have your own counsel review consent and policy wording.