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Consent Form

Optimal Performance Physical Therapy, PC uses telehealth in the delivery of his consultation and treatment sessions. Telehealth involves the use of electronic communication for the purpose of gathering individual patient medical information to provide patient care. The information may be used for diagnosis, therapy, follow-up and/or education. This may include any of the following: patient medical records, medical images, live two-way audio and video. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.


As with all forms of medical treatment, there are potential risks involved with telehealth.  These risks may include, but are not limited to: 

In rare cases, the practitioner may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled video consult;

  • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;

  • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;

  • In some cases, a person’s condition is not suitable for virtual assessment and treatment.  If so, the therapist will recommend a physician or clinic that is specialized.

  • In rare cases, there is a risk that your treatment may cause pain or injury, or may aggravate previously existing conditions.


Since the physical response to a specific treatment can vary widely from person to person, it is not always possible to accurately predict your response to certain modality recommendations or exercise/manual therapy prescriptions. 

By checking the box associated with “Informed Consent”, You acknowledge that you understand and agree with the following:

  1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth, and that no information obtained in the use of telehealth, which identifies me, will be disclosed to researchers or other entities without my written consent.

  2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.

  3. I understand that telehealth may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.

  4. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.

  5. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. The above-mentioned person will all maintain confidentiality of the information obtained.


Patient Consent to the use of Telehealth

I have read and understand the information provided above regarding telehealth, have discussed it with my physical therapist as may be designated, and all of my questions have been answered to my satisfaction.

I have read this document carefully, and understand the risks and benefits of the teleconferencing consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telemedicine visit under the terms described herein.

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