Capitol Physical Therapy: CONSENT FOR COMMUNICATION

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I, the undersigned, do hereby agree and give my consent for Capitol Physical Therapy LLC to furnish medical care and treatment that is considered necessary and proper in diagnosing or treating my physical condition.

P.S: Please note that if for some reason you are having trouble filling this form, you can download a pdf copy of this form, print it out and fill offline at www.capitolptdc.com/new-patient-forms/

To find out how we keep your information secure, please visit https://support.google.com/a/answer/3407054?hl=en

Indicated below are individuals whom Capitol Physical Therapy LLC may speak to regarding my treatment. Please list names and their phone numbers. (one person per line) *

For e.g John Doe - (202)-555-5555

Listed below are individual(s) whom I request restriction regarding my protected health information. Please list names (one person per line).

We may need to contact you. Do we have your permission to leave a confidential message at the phone numbers you have provided us? *

Yes

First Name *

Your First Name

Last Name *

Your Last Name

Today's Date *

YYYY

Emergency Contact Name *

Emergency Contact Phone Number *

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