KLS Physical Therapy P. S.
960 Harris Ave, Suite 203, Bellingham, WA 98225
360-788-2940 (F) 36-746-3140
Conditions and Consent for Physical Therapy
Cooperation with treatment: I understand that in order for physical therapy to be effective, I must
come as scheduled, unless there are unusual circumstances that prevent me from attending
therapy. I agree to cooperate and carry out the home physical therapy program assigned to me. If
I have difficultly with any part of my treatment program, I will discuss it with my therapist.
Patient/Provider Relationship: I understand that I am a patient of Kelly Lunda, who is an
independent Physical Therapist practitioner at 960 Harris Ave, Suite 203, Bellingham, WA
98225. This office is not a group practice, but rather a facility where independent practitioners
share office space. My care is the exclusive responsibility of Kelly Lunda Sampson, not of any
other practitioners who also practice at this location.
No Warranty: I understand that the physical therapist cannot make any promises or guarantees
regarding a cure for or improvement in my condition. I understand that my physical therapist will
share with me her opinions regrading results of physical therapy for my condition and will
discuss treatment options with me before I consent to treatment.
Informed Consent to Treatment: The term “informed consent” means that the potential risks,
benefits and alternatives of physical therapy treatment have been explained to you. The therapist
provides a wide range of services and I understand that I will receive information at the initial
visit concerning the treatment and assessment options available for my condition.
Potential Risks: You may experience an increase in your level of pain or discomfort, or an
aggravation of your existing injury. This discomfort is usually temporary; if it does not subside
in 24 hours. I agree to communicate this to my physical therapist by phone or on the next visit.
Potential Benefits: Potential benefits may include an in improvement in your symptoms and an
increase in your ability to perform your daily activities. You may experience increased strength,
awareness, flexibility and endurance in your movements. You may experience decreased pain
and discomfort. You will have greater knowledge on managing your condition and the resources
available to you.
Alternatives: If you do not wish to participate in the therapy program, you may discuss your
medical, surgical or pharmacological alternatives with your physician or primary care provider.
Release of medical records: I authorize the release of my medical records to my physician or
primary care provider.
Patient signature
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