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Informed Consent to Treat

I,                                          understand that I will be participating in private, one-on-one physical therapy, incorporating hands-on treatment, manual passive stretching, joint mobilization, kinesiotaping, improve my strength, endurance, flexibility, balance, core strength, and overall health and wellness, cupping, dry needling, electrical stimulation (e-stim), exercise, and other traditional conservative treatment techniques clinically indicated.


I understand that my physical therapist is licensed in the Commonwealth of Massachusetts and is educated and highly-trained in the areas above. Northshore Mobility & Wellness PT, LLC does not guarantee what your reaction will be to a specific treatment, nor does it guarantee that the treatment will help resolve the condition that you are seeking treatment for.


By signing below, I am giving my consent to treatment ("informed consent"). And, I also consent for treatment to occur in my home, gym, workplace, hotel room, or other location previously agreed upon.


I have been instructed by my physical therapist to alert my therapist of any special needs, injuries, preferences, or considerations prior to starting the first visit evaluation and treatment, as these could affect my safety and security during the treatment process. I provide this release with the understanding that my therapist is fully trained and upholds an active Ma. license. I understand that by signing below,I release this physical therapist of all liabilities for any personal harm, my health and my safety during my participation in this treatment process.


Payment Policy

Payment is due at the time of service. Payment, in the form of cash, check,Venmo, or credit card, is due at the time of each visit. Northshore Mobility & Wellness PT, LLC prioritizes relationships with patients’ not insurance companies. We do not contract with any insurance companies. However, the payments you make may be reimbursable by your insurance company under your out-of-network physical therapy benefits; the exact percentage depends upon your plan. Due to the complex nature of insurance claims and reimbursement, Northshore Mobility & Wellness PT, LLC cannot guarantee as to whether you will receive reimbursement. We will provide you with the documentation necessary to submit reimbursement upon request.


Cancellation Policy

Consistent attendance and adherence to the planned treatment regimen is paramount to your care and recovery. While we are sensitive to the fact that an emergency may occur, cancellations, tardiness and absentees reduce our ability to accommodate the scheduling needs of our patients. As such, we request your full cooperation with the following company policy: A scheduled appointment must be canceled at least 24 hrs in advance or a $25 fee will be charged. No Show/Not Home Not Found a $50 fee will be charge to your account. Two consecutive absences without advanced notification may result in the cancellation of all your remaining scheduled appointments.*Please note that a cancellation fee will not be charged if the missed appointment is rescheduled within a week of the tardiness, absence or late cancellation and another appointment was not previously scheduled for the same week.

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