Westlake Sports Therapy Inc. - Patient Information:

I clearly understand that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable within thirty days. I also understand that if my payment is late, an appropriate late fee will be added to my balance and or collection fees. Likewise, any cancelled appointments made without 24 hours notice or a “no-show” appointment will result in a fee billed directly to the patient.

I hereby instruct my insurance company to make direct payment to my provider, and or in care of myself, Tito Ramirez MPT OCS. I also authorize the release of any information pertinent to my case such as medical records and or reports to my insurance company, adjuster or attorney involved.

I hereby request and consent to the performance of physical therapy on me (or on the patient named below, for whom I am legally responsible) by the provider or intern, affiliated with Westlake Sports Therapy Inc.

I understand that, as in the practice of medicine, in the practice of physical therapy there are some risks to treatment, including but not limited to, fractures, disc injuries, strokes, dislocations and sprains. In addition, Graston Technique (GT) is an instrument-assisted variation of traditional cross fiber or transverse friction massage. GT is a form of treatment used to “break up” or “soften” scar tissue, thus allowing for the return of normal function in the area being treated. Graston Technique may produce the following: Local discomfort during the treatment, reddening of the skin, superficial tissue bruising, and or post treatment soreness. I do not expect the provider to be able to anticipate and explain all risks and complications. I wish to rely on the provider to exercise judgment during the course of the procedure, which the provider feels at the time, based on the facts then known, is in my best interests.

I have read, or have had read to me, the above consent. By signing below I agree to the above, and allow the provider or intern, affiliated with Westlake Sports Therapy Inc. to perform such. I intend this consent from to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.