Voltex Physical Therapy – Consent to Treat (Community Partnerships & Pro Bono Care) Please enable JavaScript in your browser to complete this form.Thank you for allowing us to be part of your care. General Consent for Treatment Dry Needling Information and ConsentBenefits may include:Risks are rare but possible. These include: Please tell us if you:Voluntary Participation and No-Cost Care tell Treatment Sharing Privacy and Information SharingPhoto/Media Release (Optional)Photo/Media Release (Optional)I give permission to Voltex Physical Therapy to take and use photos, videos, and testimonials of me for promotional and educational purposes. I understand that my name will not be used unless I give additional written permission.Voltex Physical Therapy occasionally takes photos or videos during sessions, workshops, and events to share on social media, our website, or in marketing materials. These visuals are used to promote health education and community outreach. Limitations and DisclaimersAcknowledgment and SignatureBy signing below: *I confirm I have read and understand this form.I give permission for Voltex Physical Therapy to provide care during this event or partnership program.I understand the risks and benefits of dry needling and give my consent, if this treatment is used.I know I can stop or refuse treatment at any time.I understand I will not be charged for these services.I have selected my preference regarding media/photo use above.Printed Name: *Signature: *Date:Clinician Name (Print): *Clinician Signature: *Submit
