List Anyone You Give Us Permission to Discuss Your Medical Care With:

Insurance Information: We MUST Have A Copy Of All Insurance Cards On File

Direct Access Attestation and Medical Release

 (Licensed health practitioners include a Doctor of Medicine, osteopathy, chiropractic, podiatry, dental surgery, licensed nurse practitioner, or licensed physician assistant) 

Consent for Treatment

I understand that I am a patient of Tristar Physical Therapy and they're independent physical/occupational/speech therapy practitioners. My care is the exclusive responsibility of the practitioners of Tristar Physical Therapy.

Cooperation with treatment: For therapy treatment to be effective, I must come to scheduled appointments unless there are unusual circumstances. I understand and agree to cooperate with and perform the home therapy program intended for me. If I have trouble with any part of my treatment program, I will discuss it with my therapist.

No warranty: I understand that there are no guarantees regarding a cure for or improvement in my condition. I understand that my therapist will outline and discuss goals of therapy treatment for my condition and will discuss treatment options with me before I consent to treatment.

Informed consent for treatment: The term "informed consent" means that the potential risks, benefits, and alternativesof therapy treatment have been explained to me. The therapist provides a wide range of services and I understandthat I will receive information at the initial visit concerning the treatment and options available for my condition.

Potential risks: I may experience an increase in my current level of pain or discomfort, or an aggravation of my existing injury or condition. This discomfort is usually temporary; if it does not subside in a reasonable time, I agree to contact my therapist.

Potential Benefits: I may experience an improvement in my symptoms and an increase in my ability to perform daily activities. I may experience an increase in strength, awareness, flexibility, and endurance in my movements. I may experience decreased pain and discomfort. I should gain a greater knowledge about managing my condition and the resources available to me.

Alternatives: If I do not wish to participate in the therapy program, I will discuss my medical, surgical, or pharmacological alternatives with my therapist, as well as my Physician or Primary Care Provider.

Payment: I understand that I am responsible for any charges not covered by my insurance. 

By providing your contact information and scheduling an appointment with our healthcare provider, you consent to receiving SMS and/or email messages regarding your appointment status, plan of care, and follow-up visits. These messages may include reminders, updates, and other pertinent information related to your healthcare.

Additionally, we may also send messages to follow up with you about your current health status throughout and after your plan of care. These messages are designed to help us provide you with the best possible care and may include questions about how you are feeling, any symptoms you are experiencing, and other relevant health-related inquiries.

You can opt out of receiving SMS and email messages related to your healthcare at any time by replying STOP to any message.

We take your privacy seriously and will only use your contact information for the purposes outlined above. You have the right to withdraw your consent at any time by contacting our office and requesting to opt-out of these communications.

By continuing to receive these messages, you acknowledge that you have read and understood this statement, and agree to the terms outlined herein.

I have read the above information and I consent to Physical Therapy Evaluation and treatment. 


Missed Visit Policy

At Tristar Physical Therapy, we aim to help all patients reach a fully recovered state. Your physical therapist will provide you with your plan for care during the evaluation appointment and will inform you of the required number of visits to help you achieve your goals. Patients who attend all physical therapy visits are 93% more likely to recover from an injury fully. In contrast, those that miss even one visit have a lower potential for recovery. We are happy to share a copy of this study with you, but we want to ensure that you understand that attending your appointments is extremely important. This policy ensures that all patients can receive the care they need.

Please read our policy and sign at the bottom indicating you understand our expectations and our policy.

1. As experts, we know you will not recover fully if you do not attend your appointments. To help ensure you have the best chance at recovery, we will work with you to schedule all of your appointments after your evaluation today, and to have the best chance at recovery; you will need to attend each visit.

2. Please note: We aim to begin your treatment sessions on the schedule. For all appointments after your evaluation, we ask that you arrive at least 5 minutes before your appointment time, dressed for your session, and ready to begin on time. This will allow our front office to handle their responsibilities and our specialists to provide the care you need and deserve.

3. If you're late for your appointment, you're missing the time that we have specifically scheduled for your care, and we cannot guarantee that we will be able to provide you with your full treatment as we have reserved the appointment time following yours for someone else.

4. If you're running late, we need you to call us immediately so we can prepare for your late arrival and consult with your clinician. If you are more than 15 minutes late, your session may need to be rescheduled, and we reserve the right to charge our missed visit fee for the lost session. Chronically late patients will be asked to change their appointment times.

5. While we understand that illness can strike at any time, we still expect that you will work to provide notice as soon as you feel sick and cannot attend a scheduled appointment.

6. Providing care to all patients is extremely important to us, and late notice of changes or cancellations will keep someone else from getting the care they need and deserve. If you need to cancel or change a scheduled appointment for any reason, we require a 24-hour notice, so we have enough time to help other patients who need to get in for the care they need and deserve.

7. When you call to cancel an appointment, have your schedule ready; we will reschedule you immediately.

8. We reserve the right to charge a missed visit fee of $50.00 if you do not provide at least 24-hour notice of your appointment change or cancellation, and we will comply with payer policy in carrying it out.

9. To avoid our missed visit fee, we need you to call our office - at least 24 hours in advance for any illness, appointment changes, or cancellations. We have an answering machine that is on 24hrs a day, seven days a week, to leave messages. You will receive text message appointments. You will also receive text messages asking you how your progress is going with your therapy. You are welcome to respond. However, if you need to contact our office to reschedule/cancel, you must call the office. Our front office does not have access to the text messages.

10. Patients with multiple same-day cancellations or no-shows will be removed from the active schedule and placed on the day-to-day list to avoid future missed visit charges. We will also notify your physician.

11. If you are a worker's comp, we must notify your claims adjuster if you cancel or are a no-show for an appointment.

We look forward to working with you to meet your physical therapy goals. To avoid any issues with our policy, we only need the required notice so we have enough time to help all patients to get in for the care they need and deserve.

Tristar Physical Therapy Management

This policy has been verbally reviewed this policy with me, and by signing below, I am indicating that I understand this policy.


I hereby acknowledge and consent to the receipt of information from this healthcare facility via any contact details I have provided.