• 2944 Hunter Mill Rd, #103, Oakton, VA.
  • Call Us: (703) 261-6005
  • Mon - Fri:   9:00am - 6:00pm

Direct Access Patient Attestation and Medical Release Form

Direct Access Patient Attestation And Medical Release Form

Family Physical Therapy and Wellness, LLC

I understand that the current course of Physical Therapy care will not last more than 60 consecutive days, and that additional Physical Therapy services for the symptoms listed on this form shall only be upon the referral and direction of a licensed health practitioner. To receive additional Physical Therapy services beyond this 30-day period, I will be required to obtain a referral from the licensed health care practitioner named above.

I understand that the practitioner named above will be provided a copy of my initial evaluation and patient history within 14 days. I HEREBY CONSENT TO THE RELEASE OF MY PERSONAL HEALTH AND TREATEMENT RECORDS TO THE PRACTITIONER NAMED ABOVE.