JOINT EFFORT MANUAL PHYSICAL THERAPY
INFORMED CONSENT
Conditions of, and Consent for Treatment: I hereby request and authorize Joint Effort Manual Physical Therapy, LLC to
perform therapy on me. I understand that I am a patient of Joylin Zimmerman, PT, CMPT, an independent Physical Therapy
practitioner practicing under Joint Effort Manual Physical Therapy, LLC at 549 N. Wymore Rd. Maitland, Florida 32751. I
consent to treatment, which will include external and possibly internal vaginal and/or rectal assessment, and treatment.
The term “informed consent” means that the potential risks and benefits of physical therapy treatment have been explained
to me. The therapist provides a wide range of services and I understand that I will receive information at the initial visit
concerning the treatment and options available for my condition.
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 with and carry out the home
physical therapy program assigned to me. If I have difficulty with any part of my treatment program, I will discuss it with my
therapist.
No Guarantees: I understand that Joint Effort Manual Physical Therapy, LLC and Joylin Zimmerman, PT, CMPT cannot make
any promises or guarantees regarding a cure for or improvement in my condition. I understand that Joylin Zimmerman, PT,
CMPT will share with me her opinions regarding potential results of physical therapy treatment for my condition and will
discuss treatment options with me before I consent to treatment.
Potential risks: I understand that this treatment may cause temporary minor soreness or an aggravation of my existing injury.
This discomfort is usually temporary and minimal. I agree to notify my therapist and physician immediately if I experience
any of the following: fainting, dizziness, lightheadedness, or shortness of breath, accompanied by weakness, loss of color, or
persistent bleeding. If any adverse side effects occur during the course of treatment, I will consult my physician. I understand
that there may be some possible vaginal spotting after internal treatment and that this is normal.
Potential benefits may include an improvement in my symptoms and an increase in my ability to perform my daily activities.
I may experience increased strength, awareness, flexibility and endurance in my movements. I may experience decreased pain
and discomfort. I should gain a greater knowledge about managing my condition and the resources available to me.
Physician Screening: I have been advised to consult my physician prior to treatment in order to minimize any potential risk
for complications. By signing below, I state that I have been cleared by my physician for any conditions which would be
contraindications to treatment. These include cancer, hemophilia, abnormal cysts, abnormal bleeding, active infection or
inflammation, HIV endometrioma, and any condition, which may be exacerbated by manual therapy treatment.
Physical Therapist: I understand that Joylin Zimmerman, PT, CMPT is a licensed physical therapist in the state of Florida. I
understand that her experience, training and educational background is limited to that required of her respective professions.
As a result, she does not and cannot provide medical care, oversight and/or supervision.
Release of medical records:
I authorize the release of my medical records to my physicians/primary care provider or insurance company. Please list.
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I certify that I have read the contents of this document. I understand the basic nature of the procedure, the risks involved,
and I consent to physical therapy evaluation and treatment. By signing below, I acknowledge that I have read, understood
and will abide by the conditions and policies noted on this consent form.
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Print Name
Date
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Patient’s signature
Therapist Signature / Date
(If minor, parent or legal guardian must sign)