I hereby consent to evaluation and treatment by my Physical Therapist at Tailwind Physical Therapy. I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examinations, test results, diagnoses, treatment, and any plans for future care of treatment. I understand and have been provided with a Notice of Privacy Practices that provides a more complete description
of information uses and disclosures, I understand that I have the right to review the notice prior to signing this consent.
Check the boxes next to each statement to confirm your consent: