Physical stress at work: Please enter a percentage of time you perform the following activities at work:
Please list 3 activities in your life you are unable to perform or having the most difficulty performing as a result of your injury or problem. Functional limitations are REQUIRED by your insurance company to justify coverage for your treatment.
I understand that I have the right to ask and have any questions answered prior to receiving any treatment, including any risks or alternatives to this treatment plan that has been prescribed by my physician and/or my physical therapist. Revive Physical Therapy & Wellness, PLLC has described for me my individual treatment plan. By signing this agreement, I consent to have Revive Physical Therapy & Wellness, PLLC provide treatment and medical care as prescribed by my physician and/or by my physical therapist.