Consent for Treatment and Acknowledgment

I the undersigned, do hereby agree and give consent for Boom Therapy, LLC to furnish medical care and treatment necessary in treating my physical condition. *
I the undersigned, do hereby agree and give consent for Boom Therapy, LLC to furnish medical care and treatment necessary in treating my physical condition.
I acknowledge that I have been given access to a virtual copy of the Practice's "HIPPA Privacy Policy Notice" , which describes the Practice's obligations to ensure the privacy of my health information. The HIPPA Privacy Notice also describes how the Practice may use or disclose my health information for treatment, payment and health care operations. I know that I have the right to review the Practice's HIPPA Privacy Notice and to ask questions about it. I understand that the Practice is required to maintain the privacy of my health information in accordance with the terms of its HIPPA Privacy Notice. I further acknowledge that the Practice can change its HIPPA Privacy Notice in the future and that I can receive a copy of the Practice's current HIPPA Privacy Notice at anytime. I understand that I have the right to request that the Practice restrict its users and disclosures of my health information for treatment, payment or health care operations. If my restrictions are accepted by the Practice, these restrictions will be binding on the Practice. I also understand that the Practice is not required to agree to my requested restrictions. By signing this form, I consent to the Practices; use and disclosure of my health information for treatment, payment and health care operations. I understand that I have the right to revoke this consent at any time in writing, but if I do, my revocation will not have an effect on any of the actions the Practice has already taken in reliance of this consent. *
I acknowledge that I have been given access to a virtual copy of the Practice's "HIPPA Privacy Policy Notice" , which describes the Practice's obligations to ensure the privacy of my health information. The HIPPA Privacy Notice also describes how the Practice may use or disclose my health information for treatment, payment and health care operations. I know that I have the right to review the Practice's HIPPA Privacy Notice and to ask questions about it. I understand that the Practice is required to maintain the privacy of my health information in accordance with the terms of its HIPPA Privacy Notice. I further acknowledge that the Practice can change its HIPPA Privacy Notice in the future and that I can receive a copy of the Practice's current HIPPA Privacy Notice at anytime. I understand that I have the right to request that the Practice restrict its users and disclosures of my health information for treatment, payment or health care operations. If my restrictions are accepted by the Practice, these restrictions will be binding on the Practice. I also understand that the Practice is not required to agree to my requested restrictions. By signing this form, I consent to the Practices; use and disclosure of my health information for treatment, payment and health care operations. I understand that I have the right to revoke this consent at any time in writing, but if I do, my revocation will not have an effect on any of the actions the Practice has already taken in reliance of this consent.
I do not request any restrictions on the Practice's uses and disclosures of my health information for treatment, payment or health care operations
I do not request any restrictions on the Practice's uses and disclosures of my health information for treatment, payment or health care operations
Date Of Birth *
Date Of Birth
Name *
Name

History Of Injury

Include the side of your body - Right, Left or Bilateral
Example: climbing stairs; reaching overhead; bending over to tie shoes
Example: rest; ice; medication; massage
Example: cortisone injection; chiropractic care; massage
Name *
Name
Date *
Date

Medical History

Name *
Name
Date of Birth *
Date of Birth
Please mark if you have ever had any of the following: *
Please mark if you have had any of the following diagnostic testing:
Primary Care Physician:
Primary Care Physician:
Primary Care Physician Phone Numer:
Primary Care Physician Phone Numer:
Primary Care Physician Fax Number:
Primary Care Physician Fax Number:
Please provide your electronic signature *
Please provide your electronic signature
Today's Date *
Today's Date

Patient Specific Functional Scale

Instructions: Please identify up to three important activities that you are unable to do or are having difficulty with as a result of your injury or problem. Today, are there any activities that you are unable to do or having difficulty with because of your injury or problem?  

0 = unable to perform activity // 10 = able to perform activity at the same level as before injury or problem
0 = unable to perform activity // 10 = able to perform activity at the same level as before injury or problem
0 = unable to perform activity // 10 = able to perform activity at the same level as before injury or problem
Name *
Name
Date *
Date

PSFS developed by: Stratford, P., Gill, C., Westaway, M., & Binkley, J. (1995). Assessing disability and change on individual patients: a report of a patient specific measure. Physiotherapy Canada, 47, 258-263.