Tell Us Your Story

Name(Required)

First Last

Date of Birth(Required)

Reason for Visit(Required)

Clinician Name:

What was your injury or problem and what did it stop you from doing prior to coming to therapy?

What goal did you want to achieve when you started therapy?

How did therapy help you achieve that goal?

What would you want people to know about ACCESS PT if they're nervous or skeptical?

Anything else we should know about the therapy you received or your experienced?

Permissions(Required)

I give my permission for ACCESS PT to use my name and share comments about my treatment and experience as a patient in communications produced by or on behalf of ACCESS PT.

Public Use(Required)

The above has been explained to me and I understand the interviews taken for marketing or publicity purposes may be used for publications and/or broadcast by the media, for public affairs purposes, including publications, advertisements, displays and/or placement on the Confluent website. I hereby waive all rights that I may t o any claims for payment or royalties in connection with the use of these photographs, audiotapes, videotapes and interviews and agree that these shall at all times be the property of Confluent.

Protected Health Information(Required)

I understand that all interviews taken for purposes of education and/or performance improvement will be protected health information ("PHI") and will be maintained in a protected and secure manner with access restricted t o the minimum necessary to carry out the aforesaid functions. I may receive copies o f any such PHI upon request and a reasonable fee may be charged for any associated costs.

Re-Disclosure Agreement(Required)

I understand that any personal health information or other information released may be subject to re-disclosure and may no longer be protected by applicable federal and state privacy laws. I further understand that this authorization is voluntary, without compensation, and that 1 may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment or receive payment from my insurance company. It will also not affect my eligibility for benefits.

Consent(Required)

I understand that this consent is subject to revocation/withdrawal by me a t any time in writing to employee who received the consent, except to the extent that action has already been taken to release this information. I have a right to receive a copy of this authorization.

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