Appointments

Billing Information

Limited medical information, such as: normal results, generic recommendations, or referral status, or updates on any of the following phone numbers listed on patient information form:

Home

Mobile

Work

And/Or with the following person(s):

First Name

Last Name

Phone

(###)

###

####

This release will be revoked by written permission only. I understand that I must send a written request to Comprehensive Physical Therapy in order to revoke this request. When translation services are utilized, you give express consent that it may be done using a wireless mobile device. Consent to Email or Text Usage for Appointment Reminders and Other Healthcare Communications: Patients in our practice may be contacted via email and/or text messaging to remind you of an appointment, to obtain feedback on your experience with our healthcare team, and to provide general health reminders/information. If at any time I provide an email or text address at which I may be contacted, I consent to receiving appointment reminders and other healthcare communications/information at that email or text address from the Practice. By typing your first and last name in the boxes below you are agreeing to ALL of the above information

Patient Name

First Name

Last Name

Date of Birth

MM

DD

YYYY