Consent Form

CONSENT, DISCLOSURE, AND PRIVACY

I hereby give consent to Dr. Natalie Hoff Physical Therapy, PLLC dba First Off Wellness to provide the desired services, as requested by myself, or my family member(s).

I, or my family, have provided full disclosure of any and all relevant past medical history that may impact, influence or contraindicate the prescribed service provided by Dr. Natalie Hoff Physical Therapy, PLLC dba First Off Wellness.

I understand that DDr. Natalie Hoff Physical Therapy, PLLC dba First Off Wellness. is fully licensed and its providing therapists are highly trained and skilled. They (Dr. Natalie Hoff Physical Therapy, PLLC therapist) will ensure that the service they provide is safe, appropriate, and indicated for my condition.

While Dr. Natalie Hoff Physical Therapy, PLLC dba First Off Wellness. fully intends to give service that offers no harm, I understand that there is ALWAYS THE POTENTIAL FOR AN UNFORESEEN ACCIDENT TO OCCUR. Should this be the case, I recognize that Dr. Natalie Hoff Physical Therapy, PLLC has taken every necessary precaution to protect me, and therefore, I DO NOT HOLD Dr. Natalie Hoff Physical Therapy, PLLC dba First Off Wellness liable for any unforeseen injury.

Dr. Natalie Hoff Physical Therapy, PLLC dba First Off Wellness ensures that information about me and my condition, or reason for receiving services, will remain private and be fully disclosed ONLY upon my approval.

First name of Patient

Last name of Patient

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CONSENT, DISCLOSURE, AND PRIVACY

I hereby give consent to Dr. Natalie Hoff Physical Therapy, PLLC dba First Off Wellness to provide the desired services, as requested by myself, or my family member(s).

First name of Patient

Last name of Patient

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Name of Patient Representative (if applicable)

Relationship to Patient

Signature of Patient Representative

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date picker