Forms & Agreements

Please review and sign the required documents before your first visit.

Consent to Treat

Action Required

1. Consent for Treatment

I hereby authorize Tritone Physical Therapy & Wellness to evaluate and treat my condition. I understand that physical therapy may involve risks such as muscle soreness, strains, or exacerbation of symptoms, and I voluntarily accept these risks.

2. Patient Responsibilities

I agree to participate actively in my treatment program and follow the home exercise programs prescribed to me. I understand that failure to comply may result in sub-optimal outcomes.

3. Cancellation Policy

I acknowledge the 24-hour cancellation policy and understand that I may be charged a fee for late cancellations or no-shows.

I have read and agree to the Consent to Treat policy.

HIPAA Notice of Privacy Practices

Signed on 10/21/2023

Communication Consent

Action Required

I consent to receive communication from Tritone Physical Therapy & Wellness regarding my appointments, treatment, and billing via:

  • Email
  • SMS / Text Messages
  • Phone Calls

I understand that standard data rates may apply for text messages. I may opt out of marketing communications at any time by replying STOP to any text message or contacting the clinic directly.

I agree to the Communication Consent terms.

Membership & Payment Agreement

Action Required

1. Financial Responsibility

I agree to be financially responsible for all charges incurred at Tritone Physical Therapy & Wellness. I understand that payment is due at the time of service unless other arrangements have been made in advance.

2. Memberships and Packages

If I am enrolled in a membership or wellness package, I agree to the specific billing terms outlined in my selected plan. Memberships auto-renew on a monthly basis and require a 30-day written notice for cancellation.

3. Insurance

I understand that Tritone Physical Therapy & Wellness is an out-of-network provider and does not bill insurance directly. I will be provided with a superbill upon request to submit to my insurance company for potential reimbursement.

I have read and agree to the Membership & Payment terms.