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I hereby consent to the rendering of physical therapy services by 40 31 Physical Therapy and Fitness PLLC 40 31 PTF as described to me or as my physician or 40 31 Physical Therapy and Fitness PLLC determines are necessary. You have the right to request restriction on the usage and disclose of your protected health information request if we do the restriction will be obligatory to us. I acknowledge that no guarantees have been made to me about the outcome of treatment. CONSENT OF DISCLOSURE...
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Start by locating the designated space on the form or document where you are required to fill out your name. It is usually labeled as "Name" or "Full Name".
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Write the current date in the prescribed format. This may vary depending on the document, but often includes the day, month, and year. For example, you can write the date as "February 25, 2022" or simply as "25/02/2022".
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Name must be printed with the current date.
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Name should be filled out with the current date included.
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The purpose of printing name with the date is to provide accurate information.
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All relevant information must be reported along with the printed name and date.
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