Vanderbilt Dayani Center for Health and Wellness______
Vanderbilt University Medical CenterPatient Name
Physical Therapy
Phone (615) 322-4751
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Informed Consent for Physical TherapyMedical Record Number
Explanation of Physical Therapy at the VanderbiltDayaniCenter
A physician’s referral is required prior to your appointment. You will be evaluated by one of our physical therapists (PT), with progress notes by a PT every month. Your PT plan of care and exercise program will be based upon information gathered from your referring physician, your medical record/history and information from your evaluation. You will be given instructions regarding the amount and kind of physical activity you should do. Physical therapy at the VanderbiltDayaniCenter specializes in manual therapy, myofascial release, aquatic and land-based programs. Your treatment plan will always include a progressive exercise program addressed each time you attend. Therapy will be provided by either licensed physical therapists and/or licensed physical therapist assistants. At times student physical therapists also treat our patients under the supervision of our physical therapy staff following normal practice, medicare and insurance guidelines.
We have a full length pool for aquatic therapy, aerobic and nautilus type strengthening machines in a gym setting, an indoor track and individual treatment rooms where therapists evaluate, teach home exercises and provide any needed modalities and manual therapy. Our approach encourages patients towards independence in their exercise and stretching program and making fitness a lifestyle change. Continuation of physical therapy treatment after the first month progress note will be based on your functional progress and adherence to your exercise program, as insurance and PT professional standards mandate this. Range of physical therapy treatment sessions at the VanderbiltDayaniCenter for Health and Wellness is 6 to 18 with an 18 visit maximum. Our charges are set system wide at Vanderbilt, and your insurance may not cover all costs. Please check with our scheduling staff or your therapist for exact details.
Risk and Discomfort
There exists the possibility of certain changes occurring during your session from exercise,manual therapy or modalities. These include pain and stiff or sore muscles during and sometimes after treatment. These symptoms should subside within 24 to at most 48 hours, and we often suggest ice and good hydration to control pain. There is a rare chance of bruising with manual work, but this also should resolve in a few days. As with any patient who is walking, doing transfers or balance or strengthening exercises, there is a small risk of a fall. If your therapist is providing modalities, any risks will be described to you prior to your first session, and you can decide at that point whether you wish to proceed. Every effort will be made to minimize any risk to you. It is vital that you report any new or unusual symptoms you might experience during or after treatment.Emergency equipment and trained personnel are available to deal with unusual situations that may arise.
Responsibility of the Participant
To benefit from your physical therapy program, we ask you to give priority to regular attendance and adherence to prescribed amounts of intensity, duration, frequency, progression, and type of activity that you have been given. To safely experience the maximal benefits fromthis program we ask you to comply with the following guidelines:
DO NOTwithhold any information pertinent to symptoms from the physical therapy staff
DO NOTexercise if you don’t feel well
DO report any new or unusual symptoms that you might experience before during or after
exercise or treatment
DO report any new change in your medicines or medical care as indicated by your physician
DO follow instructions carefully when usingexercise equipment
Attendance Expectations:
- Please make sure to attend all scheduled therapy appointments
- Please arrive ahead of your scheduled appointment time to park and register so therapy can begin on time
- Your session will include time to discuss the therapy program, prepare and clean treatment area, and to document session
- If you will be late for a scheduled appointment, please contact the front desk at (615) 322-4751. If you are more than 20 minutes late, your appointment may need to be rescheduled
- If you know that you will be out of town or have a scheduling conflict, please call the front desk at (615) 322-4751 at least 24 hours in advance
Canceling and Missing a Scheduled Appointment:
- To cancel or reschedule, please call the front desk at (615) 322-4751 at least 24 hours in advance
- Extended planned vacations must be discussed with your clinician to determine impact on progress. Sessions must be re-scheduled in advance in order to prevent regression of skills and possible discharge from therapy
- If you miss 3 appointments without calling 24 hours in advance, you will be discharged from therapy and your referring physician will be notified
Use of Medical Records
The information obtained during your medical screening and while participating in the Physical Therapy Program will be treated as privileged and confidential. It will not be released or revealed to any person except your referring physician without your written consent. The information obtained, however, may be used for statistical analysis or scientific purposes with your right to privacy retained.
Inquiries
Any questions about your physical therapy program are welcome. If you have any questions or concerns, please contact the staff for assistance.
Freedom of Consent
Your permission to engage in the physical therapy program is voluntary. You are free to deny any consent if you so desire, both now and at any point in your program.
I acknowledge that I have read this form in its entirety or it has been read to me, and that I understand the physical therapy program in which I will be engaged. I accept the rules and guidelines set forth. I consent to participate in this physical therapy program.
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Participant’s Signature/Date
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Professional Staff Signature/Date
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