New Client Intake Form & Policies
If you are a new client, please review the following Policies, and then fill out the form below. This is required in order to be a evaluated and treated by Erin Brooks, PT, DPT, a licensed physical therapist and founder of The Pilates PT, LLC.
For physical therapy:
I hereby consent to the evaluation and treatment of my condition by Erin Brooks, PT, DPT, a licensed physical therapist and founder of The Pilates PT, LLC. Erin will explain the nature and purposes of these procedures, evaluation, and course of treatment. Erin will inform the patient and/or guardian of expected benefits and complications, and any discomforts, and risks that may arise, as well as alternatives to the proposed treatment and the risk and consequences of no treatment.
You have chosen to participate in Pilates exercise (in person and/or online) with The Pilates PT, LLC.
Exercise activity should not be undertaken without first consulting a physician, especially if you are pregnant or have any physical limitations due to age or disease or are taking medications. Please discontinue any activity that causes you pain or severe discomfort and consult a physician.
This is a standing waiver that applies to all future Pilates exercise (individual and classes) you take with The Pilates PT, LLC.
THIS DOCUMENT IS A RELEASE OF CLAIMS AND BY SIGNING IT YOU ACKNOWLEDGE AND AGREE TO THE FOLLOWING:
- I acknowledge that all exercise activity, including the use of equipment, is a potentially hazardous activity. I also understand that fitness activities involve a risk of injury and even death, and that I am voluntarily participating in these activities and using equipment and machinery with knowledge of the dangers involved.
- I am in good health and sufficient physical condition to engage in exercise activity and am voluntarily participating in this activity.
- In consideration for being allowed to participate, I agree to assume all risks of exercise. I agree to release and hold harmless The Pilates PT, LLC from any liability or responsibility for any physical injury, illness or death you may incur during, or as a result of participating in this exercise activity.
I have read and fully understand The Pilates PT, LLC’s, Notice of Information Practices. I understand that The Pilates PT, LLC. may use or disclose my personal health information for the purpose of carrying out treatment, obtaining payment, evaluating the quality of service provided, and any administrative operations related to treatment or payment. I understand that I have the right to request restrictions, in writing, regarding how my personal health information is used and disclosed for treatment, payment, and administrative operations. I also understand that The Pilates PT, LLC, will consider requests for restrictions on a case by case basis, but is not required to oblige to such requests.
I hereby consent to the use and disclosure of my personal health information for purposes as noted in The Pilatest PT, LLC’s, Notice of Information Practices. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time, at which point The Pilates PT, LLC has 30 days to respond to my request.
Payment is due at the time of service. Accepted methods of payment include cash, personal check, Venmo or Paypal. Cancellation policy is 24 hours. An appointment canceled within 24 hours of scheduled appointment will be billed the full amount. There are no refunds for physical therapy or Pilates services.