Physical Therapy Form

Please down load and fill out this form Send the PDF to us in an email or print it out and bring them with you.
OR
use our on-line form found below.

You must complete and turn in/submit this form before treatment can begin.

dPilates Physical Therapy Form

  • All services are subject to a 24 hour cancellation rule. Any appointment not cancelled before 24 hours of the scheduled time will be charged the full service rate. The studio will not charge due to cancellations for severe weather.

    All services must be prepaid. Spots cannot be held without payment.

    All services expire three (3) months from the purchase date.

    Patients are expected to be on time for their appointments. Appointments will not be extended for tardiness. Patients arriving more that 15 minutes late – without calling – will be considered a late cancellation and will be charged the full service rate.

    There are no refunds on unused services and gift certificates.
  • PERSONAL HISTORY:

  • CONSENT, ASSIGNMENT, RELEASE & FINANCIAL POLICY

    I, the undersigned, hereby agree and give my consent for d'Pilates Physical Therapy to furnish care and treatment considered necessary and proper in treating my condition(s). I also certify that I (or my dependent) have insurance coverage and assign directly to d'Pilates Physical Therapy insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid or covered by insurance. I further do hereby authorize the center to release any and all information in my chart if requested by my carrier, to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

    I also fully understand that all co-payments and/or co-insurance payments are payable at the time of service. If I have utilized my benefits entirely, I agree to pay in full upon each visit, unless special arrangements have been made with the staff of d'Pilates Physical Therapy, and that failure to do so can result in my account being turned over to collections and termination of my treatment.

    CANCELLATION POLICY

    Specific time is reserved for you when you schedule an appointment. If you cannot keep your scheduled appointment time, please give us at least 24 hours notice so that we may reschedule your appointment. There will be a charge of $50 for NO SHOW appointments or cancellations with less than 24-hours notification. You agree that you will be personally responsible for any cancellation fees.

    RETURN CHECK POLICY (NSF)

    In the event the bank returns your check due to non-sufficient funds, our office will automatically charge $25 to your account per attempt to cash your checks in addition to the amount due for the services you received.

    Please download, print and sign a copy of our Physical Therapy Waver. Bring the signed copy with you to your consultation or first session.
  • Please print out and sign our Payment Authorization form and bring it with you or use the form below to authorize payment.
 

Verification