Patient Disclosure & Medical Disclaimer

The information provided on this website is intended for educational and informational purposes only and does not constitute medical advice, diagnosis, or treatment. Use of this website, including scheduling services or submitting inquiries, does not establish a physical therapist–patient relationship.

All services offered—including but not limited to manual physical therapy, dry needling (with or without electrical stimulation), shockwave therapy, pelvic floor therapy, vestibular rehabilitation, and orthopedic care—are performed only following a comprehensive evaluation by a licensed physical therapist. Each treatment plan is uniquely tailored to the individual based on clinical findings, medical history, and personal goals.

While we are committed to delivering exceptional, evidence-based care in a professional and compassionate environment, individual results may vary. No guarantees are made regarding specific outcomes or timelines for recovery.

Certain treatments, including dry needling and shockwave therapy, may carry inherent risks and are not appropriate for all patients. A thorough consultation will be conducted to determine suitability and ensure safety prior to initiating any intervention.

If you are experiencing a medical emergency, please call 911 or seek immediate medical attention.

By using this website and/or engaging in services, you acknowledge and agree to the terms of this disclaimer.

Elevated Brand Statement (Optional but Recommended)

We are dedicated to providing a highly personalized, concierge-level approach to physical therapy—where clinical excellence, discretion, and patient-centered care define every experience.

Advance Care Physical Therapy, P.C.

Physical Therapy Department

Notice of Privacy Practices (HIPAA) This Notice describes how your medical information may be used and disclosed and how you can access this information. Please review it carefully. We are committed to protecting the privacy and confidentiality of your health information. In accordance with applicable laws, we maintain safeguards to ensure the security of your personal health information (PHI). How We May Use and Disclose Your Information Your health information may be used for the following purposes: Treatment: To provide, coordinate, and manage your care. Payment: To obtain reimbursement for services rendered. Healthcare Operations: For administrative, quality assurance, and business operations. We may also disclose your information when required by law, for public health purposes, or to prevent serious threats to health or safety. Your Rights You have the right to: Access and obtain copies of your medical records Request corrections to your records Request restrictions on certain uses or disclosures Receive confidential communications File a complaint if you believe your privacy rights have been violated Our Responsibilities We are required by law to: Maintain the privacy and security of your health information Provide you with this notice Notify you in the event of a breach Contact Information If you have any questions or concerns regarding this notice, please contact our office directly. By engaging in services, you acknowledge receipt and understanding of this Notice of Privacy Practices.

Dry Needling Informed Consent

Dry needling is a skilled technique performed by a licensed physical therapist using sterile, single-use needles to target muscular trigger points and improve pain and function.

Purpose of Treatment

Dry needling is used to relieve pain, reduce muscle tension, and improve mobility.

Potential Benefits

  • Decreased pain
  • Improved range of motion
  • Enhanced muscle function

Possible Risks and Side Effects

  • Mild soreness or bruising
  • Bleeding at the insertion site
  • Fatigue or dizziness
  • Rare risks: infection, nerve irritation, or pneumothorax (lung puncture)

Contraindications

Dry needling may not be appropriate for individuals with certain medical conditions, including but not limited to bleeding disorders, pregnancy (in certain areas), or compromised immune systems.

Patient Acknowledgment

I have been informed about the nature, purpose, benefits, and risks of dry needling. I have had the opportunity to ask questions and consent to this treatment voluntarily.

I understand that I may withdraw consent at any time.

Patient Name: ______________________
Signature: __________________________
Date: ______________________________

Consent for Treatment & Financial Policy

Consent for Treatment

I hereby consent to evaluation and treatment by a licensed physical therapist. I understand that treatment may include, but is not limited to:

  • Manual therapy
  • Therapeutic exercise
  • Dry needling
  • Electrical stimulation
  • Shockwave therapy
  • Pelvic floor therapy
  • Vestibular rehabilitation

I acknowledge that no guarantees have been made regarding the outcome of treatment.

Financial Policy

Payment is due at the time services are rendered unless otherwise arranged.

  • I understand and agree to be financially responsible for all services provided.
  • Missed appointments or late cancellations (less than 24 hours) may be subject to a cancellation fee.
  • Packages or prepaid services are non-refundable unless otherwise specified.

Insurance (if applicable)

If insurance is accepted, I understand that I am responsible for any co-pays, deductibles, or non-covered services.

Cancellation Policy

We kindly request at least 24 hours’ notice for cancellations or rescheduling.

Patient Acknowledgment

I have read and understand the above policies and agree to comply with them.

Patient Name: ______________________
Signature: __________________________
Date: ______________________________

Advance Care Physical Therapy, P.C.

Physical Therapy Department