Healthcare & Wellness

Physical Therapy Intake & Consent

Full intake and informed consent for outpatient physical therapy, covering diagnosis, treatment modalities, material risks, home exercise compliance, and ESIGN-compliant electronic authorization.

📄 1 signer📅 30-day expiry🏷 Healthcare & Wellness🔖 physical-therapy, rehabilitation, informed-consent

About this template

The Physical Therapy Intake & Consent is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 1 signer (patient) and, by default, expires 30 days after it is sent if left unsigned. It covers physical therapy, rehabilitation, informed consent. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.

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# Physical Therapy Intake & Consent **Provider / Clinic:** ___________ **Supervising Physical Therapist:** ___________ **Referral Source / Referring Physician:** ___________ **Diagnosis / Referral Reason:** ___________ --- ## Section 1 — Patient Information **Full Legal Name:** ___________ **Date of Birth:** ___________ **Sex Assigned at Birth / Gender Identity (optional):** ___________ **Address:** ___________ **City, State, ZIP:** ___________ **Primary Phone:** ___________ **Email Address:** ___________ **Preferred contact method:** ___________ **Emergency Contact Name:** ___________ **Emergency Contact Phone:** ___________ **Relationship:** ___________ **Primary Care Physician:** ___________ **Primary Care Physician Phone:** ___________ --- ## Section 2 — Insurance & Authorization

Fields (54)

clinic name
text · required
pt name license
text · required
referring physician
text
referral diagnosis
text · required
full name
text · required
date of birth
date · required
gender
text
address
textarea · required
city state zip
text · required
phone
phone · required
email
email · required
contact preference
radio · required
emergency contact name
text · required
emergency contact phone
phone · required
emergency relationship
text · required
pcp name
text
pcp phone
phone
insurance carrier
text
insurance id
text
insurance group
text
auth number
text
workers comp
radio · required
mva claim
radio · required
mva details
textarea
chief complaint
textarea · required
onset date
date · required
mechanism
textarea · required
symptom location
text · required
pain rest
number · required
pain activity
number · required
pain character
select · required
functional limitations
textarea · required
patient goals
textarea · required
prior pt
radio · required
prior pt outcome
textarea
medical diagnoses
textarea · required
surgical history
textarea · required
medications
textarea · required
allergies
textarea · required
pacemaker
radio · required
metal implants
radio · required
implant details
textarea
hx dvt
checkbox
hx osteoporosis
checkbox
hx cancer
checkbox
hx cardiac
checkbox
hx diabetes
checkbox
hx neuropathy
checkbox
hx skin
checkbox
hx pregnancy
checkbox
hx seizure
checkbox
imaging results
textarea
governing state
select · required
printed name
text · required

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Send this template with cryptographic proof

Every signed document gets PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package sealed in WORM storage.

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