welcome-central-physical-therapy-fitness-3.doc - GENERAL...

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Your Treatment/Fitness Plan: This plan is based on your medical or fitness needs as determined by your diagnosis, your doctor’s prescription, the physical therapist’s evaluation, and your goals, as appropriate. (Check the box below and fill in patient name, as appropriate.) I agree and give my consent for Seattle PT Solutions LLC to furnish medical care and treatment considered necessary and proper in diagnosing or treating: my physical condition and/or to provide fitness consultation and services for me. ____________ physical condition and/or to provide fitness services for __________________. Appointments: Your appointment time is reserved for you. Please contact us as soon as possible if you are unable to keep your appointment, so that we may offer your time to someone else. The following fee policy applies to cancellations without 24-hour notice and missed appointments. Please note that these costs are not covered by your insurance & must be paid prior to your next visit. @ MoveMend 3221 Eastlake Avenue E Suite 110, Seattle WA 98102 Phone: 206 641 7733 fax: 206 641 3272 GENERAL POLICIES
First late cancel - $15 2 nd - $30 Others - $50 1 st missed appt. $50 2 nd - $100 3 rd - $150, and we will assume discharge Privacy Practices: I have read SPTS’s Notice of Privacy Practices and understand that I have a right to a paper copy of this Notice .

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