Physical therapy — consent discussion

Complete this with your clinician after discussing your individual plan. This blank form does not collect or send information online. Keep the completed record in the practice’s secure clinical record system and give the patient a copy. Practice review of this draft is needed before adopting it as an intake form.

Consent information

Patient nameDate of discussion / clinician

What we discussed

Proposed examination, treatment and goalsExpected benefits and relevant personal risksReasonable alternatives, including waiting or declining, and their risksQuestions, answers, precautions and any limits requestedCommunication support / representative involved, if applicable

My decision

My clinician explained the proposed care and answered my questions in a way I understand. I have had an opportunity to discuss benefits, risks and alternatives. I understand that results are not guaranteed and that I may decline, pause or ask to change care.

Record one decision: agree to the care described above / agree with the limits recorded above / decline or defer.

Decision and any limitsPatient or authorized representative signature / dateRepresentative name, relationship and authority, if applicableClinician signature / date

This form does not authorize photographs, recordings, advertising or unrelated procedures. Obtain separate, specific permission when appropriate. Update the discussion when the plan or relevant risks change.