I understand that my trained physical therapist will complete a thorough evaluation and assessment in order to provide an effective and appropriate treatment plan. I understand that my physical therapist will outline and discuss goals of physical therapy treatment for my condition and will discuss treatment options with me before I consent to treatment. I understand that there are no guarantees regarding a cure for or improvement in my condition.

I understand that in order for my trained pelvic floor physical therapist at Thrive Pelvic Health and Wellness to evaluate and treat my diagnosis, it may be appropriate to have my therapist perform a pelvic floor muscle examination. The pelvic floor exam may include an external and/or internal vaginal and/or rectal exam to assess skin integrity, coordination, reflexes, tone, scar mobility, strength, and endurance. An assessment will only be initiated after full verbal consent. I understand that I may bring a chaperone, I can stop the exam at any time, I am responsible for communicating with my attentive therapist at any and all times, and that I will ask and expect answers to any questions or concerns that I may have.

I understand that attendance to scheduled sessions at Thrive Pelvic Health and Wellness improves the likelihood of symptom resolution. Attending sessions consistently and on time is important to achieve the gains and progress desired. Initialing here confirms that I will attend my scheduled sessions, and if atypical events prevent me from being able to do so, I will give my therapist at least 24 hours notice for rescheduling of follow up appointments. Cancellations within 24 hours of the appointment time will result in a charge of the full visit fee.

I understand that in the state of Indiana, you may have a Physical Therapy evaluation and treatment without a script. If treatment is deemed appropriate and desired after 42 days (6 weeks), a script is required to continue. This script can be from a physician, chiropractor, podiatrist, psychologist, dentist, physician's assistant, or nurse practitioner. If you are planning to submit a superbill to insurance for reimbursement, please inquire with your insurance provider to assess what may be necessary to see an out-of-network provider. Please let your therapist at Thrive Pelvic Health and Wellness know that you will be submitting a superbill prior to the initial evaluation, to ensure timely completion of the required paperwork.

I agree to pay for my treatments at Thrive Pelvic Health and Wellness at time of service, by cash, check, credit card, or HSA/FSA. I understand that it is my responsibility to call my insurance company ahead of time, and obtain any pre-authorization that is necessary, and get an estimate of my benefits. I understand that if requested, my therapist will provide me with a receipt and that it is my responsibility to submit to my insurance company. The rates: $175 for Initial Evaluation and Treatment, $150 for Follow up Treatments, discounted packages are available upon request. Thrive Indy PT is a cash based provider, patients with medicare cannot be seen for a service that is available via an in network provider, although can be seen for wellness only visits that cannot be submitted to insurance.

I understand that my physical therapist will be complying with HIPAA (Health Insurance Portability and Accountability Act) regarding how she may use or disclose protected health information. Protected health information will be collected by your physical therapist at Thrive Pelvic Health and Wellness in order to have records for improved consistency and quality of care. By initialing this form, you understand that: - Protected health information may be used for treatment, and that it will be kept private. - Thrive Pelvic Health and Wellness is required by law to give you this notice of our privacy practices in compliance with HIPAA regulations.