Client Consent Form - Revolution Rehab

Participants Name *

First

Last

Parent/ Guardian Name

First

Last

Phone

Email *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Consent to Treat *

I Agree

You give permission to Revolution Rehab staff to perform the necessary testing and treatment according to your diagnosis. You agree that no guarantee or promise has been made as to the results of services you are to receive nor that any treatment you receive will produce specific results. You agree to any treatment technique that is recommended by the therapist that is within the scope of our profession that can be performed by our licensed professionals.

Signature *

By typing my name I accept this as my signature

Date of Signature *

General Comments

Email Subscription

All potential and future clients will be subscribed to our free email list. This will contain helpful tips, exercises, and information to improve your overall health. If you would rather not receive this information type “Unsubscribe” above.