It is recommended you print or save this Notice for future reference.

Updated December 28, 2022

Note: The terms “you” and “your” used below refer to the consenting patient or (if patient is under the age of 18) the patient’s consenting parent/legal guardian on behalf of the patient.

1. CONSENT. You consent to physical therapy services at Dunamis. You know if you have any questions about your care, you should be sure to ask the physical therapist about them. You know it is up to you to inform the physical therapist / staff about any health problems or allergies you have. You must also tell the physical therapist/staff about drugs or medications you are taking.
2. RELEASE OF INFORMATION. Dr Scott A. Jones releases patient health care information for purposes of treatment or payment, or to other health care organizations, as explained in Notice of Privacy Practices of Dr Scott A. Jones. You authorize the release of any medical or other information pertinent to your case to any insurance company, adjuster, or attorney involved in this case for the purpose of processing claims and securing payment of benefits.
3. FINANCIAL. For any returned check, there will be a $25 fee added to your responsibility that will be included in physical therapist’s bill to you. If you do not pay the physical therapist’s bill in the specified timeframe, then your balance will be sent to a collection agency and a 35% percent fee will be added to the unpaid balance and will be your responsibility.
4. NO GUARANTEES. You understand that the practice of physical therapy is not an exact science and that no guarantees or promises have been made to me as a result of treatments or examinations by the physical therapist. You understand that no contract, warranty, guarantee, or promise concerning the results of the physical therapy services is made. This consent to treatment form is not a contract, nor is it an offer to contract, nor is it an acceptance of an offer to contract.
5. NOTICE OF PRIVACY PRACTICES. You have read the Notice of Privacy Practices of Dr Scott A. Jones (located at https://drscottajones.com/notice-of-privacy-practices-of-dr-scott-a-jones/) and you understand that a copy of the notice will be provided to you upon your request.
6. CANCEL / NO SHOW / LATE POLICY. If you must cancel your scheduled appointment, a 12-hour notice
   is required. Cancellations with less than a 12-hour notice, No Shows, and Late Shows will result in a full visit fee ($150) or visit deduction from your existing package. If you arrive 10 minutes or more late for your appointment, your therapist may not have the time to treat you or your therapy time may be reduced; however, you will be charged the full visit fee or a visit deduction from your existing package.