Patient Information and Consent Form


I hereby agree and give my consent to Axios Physical Therapy to the evaluation and treatment of my condition by a licensed physical therapist. I understand the physical therapist will inform me of the expected benefits and possible complications or discomfort, and the steps to take at home to alleviate those symptoms. All questions will be answered to the best of the therapist’s ability. I understand that the benefits and risks to all interventions will be explained and that I, the patient, hold the final judgment in such matters. I understand that in the state of Virginia, effective July 1, 2021, SB 1187 passed which allows for a qualified physical therapist to evaluate and treat patients without a referral under certain circumstances up to 60 days. Virginia Code § 54.1-3482.


I hereby authorize payment directly to Axios Physical Therapy for medical services rendered. I understand that I am financially responsible for all charges. In the event of default, I promise to pay collection costs and reasonable fees as may be required to obtain collection of this account.


Due to the nature of physical therapy, your progress and full recovery are dependent on the physical therapist, and your active participation and commitment to your appointments.


I understand that in order to protect the confidentiality of our patients, there can be no filming, going “live” via social media or taking pictures of my treatment, or that of other patients, without prior authorization from the Clinic Director.


If you need to cancel your appointment, please contact Axios Physical Therapy at least one day prior to your appointment. If you call to cancel your appointment on the same day as your appointment or if you do not show, a CANCELLATION FEE of 75% of the visit will be assessed.


I understand that authorized personnel (including my physical therapist) from Axios Physical Therapy may communicate with me via text or email regarding scheduling/ appointments, the treatment provided, home exercise programs, and educational/informative content as it relates to my condition. By my signature below, I certify that I have read, understand, and fully agree to each of the statements in this document:

If under 18, Parent/Guardian:

HIPAA Notice of Privacy Practices

Notice of Privacy Practice Describes how we may use and disclose your protected health information (PHI) to carry out our treatment, payment or health care operations and for other purpose that are permitted or required by the law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you, and that relates to your past, present or future physical or mental health or condition and related health care services. The privacy of your medical information is important to us.

We understand that your medical information is personal and we are committed to protecting it. The record we create of the care and services you receive is needed so we may provide you with the best quality care and also comply with certain legal requirements.

Uses and Disclosures of Protected Health Information We will use and disclose elements of your protect health information without your signed authorization for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physical therapist’s practice and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate or manage your health care with a third party. For example we would disclose your protected health information, as necessary, to another physical therapist’s involved in your care or to your referring physician to ensure that the physician has the necessary information to reevaluate, diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for continued physical therapy treatment may require that your relevant protected health information be disclosed to the health plan to obtain approval.

Healthcare operations: We may use or disclose as needed, your protected health information in order to support the business activities of your physical therapist practice. These activities include, but are not limited to, quality assessment activities employee reviews activities, training of physical therapy students licensing, and conducting or arranging for other business activities. For example, we may disclose your (PHI) to physical ther- apy students that see patients at our office. We may call you by name in the waiting room when your therapist is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointments.

We may use or disclose your (PHI) in the following situations without your authorization. These situations include: as Required by Law, Public Health issues as required by law, Communicable diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements; Legal Proceedings: Law Enforcements: Coroners, Funerals Directors, and Organ Donation; Research; Criminal Activity: Military Activity and National Security; Workers’ Compensation; Inmates: Required Uses and disclosures: under the law, we must make disclosures to you and when required by the secretary of the Department of Health and Human Services to Inves- tigate or determine our compliance with requirements of the section 164.500.

Other Permitted and Required uses and Disclosures Will be made Only with Your Consent, Authorization or Opportunity to object unless required by the law.

Physicians You May revoke this authorization, at any time in writing, except to the extent that your physician or the Practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights (The following is a statement of your rights with respect to your protected health information.)

You have the right to inspect and copy your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purpose of treatment, payment or health care operations. You may also request that any part of protected health information not be described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restrictions to apply. Your physical therapist is not required to agree to restriction that you may request. If the physical therapist believes it is in your best interest to permit use and disclose of your (PHI), it will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health infor- mation. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as proved in this notice.

Complaints You may complain to us or to the secretary of the Health and Human services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy officer of your complaint. We will not retaliate against you for filling a complaint.

We are required by law to maintain the privacy of, and provide individuals with this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with an HIPPA Compliance Officer by phone at (703) 372-5716 or Department of Health and Human Services Mail, fax, email, or OCR Complaint Portal


I have read and fully understand Axios Physical Therapy’s HIPAA Notice of privacy practices.

* I understand that Axios Physical Therapy may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment.

 * I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment, and administrative operations if I notify the practice.

 * I also understand that Axios Physical Therapy will consider requests for restriction on a case by case basis.

 * I hereby consent to the use and disclosure of my personal health information for purposes as noted in Axios Physical Therapy’s Notice of Information Practices.

 * I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.


What is the nature of the current injury?

List at least 3 activities that you are unable to do/having difficulty with as a result of your pain/injury AND rate them 0-10 (0 = unable; 10 = able to perform without limitations)


Health History

Do you smoke?

Do you have any allergies to latex, cold, heat or medications? If yes

List any recent diagnostics (X-ray, MRI, CT, EMG)

Are you on any medications?

Have you fallen in the past year? If yes, how many times

Past Medical History

Please Check ALL that apply

General Medical History

Please Check ALL that apply


Cardiovascular System

Please Check ALL that apply


Endocrine System


Blood Born Disease


Gastrointestinal & Urogenital System


Nervous System/ Musculoskeletal


Pulmonary System


Integumentary System


The above information I have provided is complete, true and correct to the best of my knowledge.

Emergency Contact Information