Jordan Samuel, PT, DPTClinic Director
The complimentary injury screen is a free wellness service that is designed to promote healthy pain free living (“Screen”). The licensed professional providing the Screen will not be performing a comprehensive rehabilitation therapy evaluation, but only making a determination as to whether a comprehensive rehabilitation therapy evaluation and/or referral to another health care professional is required.
The Screen is not a physical or occupational therapy treatment intervention or the provision of any other health care service that is required to be provided by an individual licensed or certified by a state licensing board, and therefore no plan of care and/or medical record will be created in conjunction with the Screen.
The Screen has no monetary value. The provider of the Screen will not bill an insurance company for the Screen. Eligibility to participate in the Screen is not conditioned upon obtaining other services from the provider of the Screen and/or using the provider of the Screen for any other service.
By my signature below, I acknowledge that I have completely read, fully understand, and agree to the terms, conditions, and content in this form; I certify that I am not a federal health care program beneficiary and that my participation in the complimentary Screen is not conditioned upon obtaining other services from the provider of the Screen and/or using the provider of the Screen for any other service; and I consent to receive a complimentary Screen.