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Patient Agreement/Waiver

I hereby request physical therapy evaluation and treatment from Harriet Levin, MSPT, hereinafter known as “physical therapist”.

If I have any medical conditions, I have consulted with a physician to ensure myofascial release, trigger point therapy and/or physical therapy are appropriate treatments.

I understand it is my responsibility to inform the physical therapist of any conditions or changes in patient health, now and ongoing, which may affect my ability to perform therapeutic exercises or to accept treatment.


I understand that all fees are due upon treatment, and I am responsible for submitting insurance claims to my insurance provider.

Protected Health Information

I understand that protected health information will not be released or disclosed to any entity without expressed, written consent from me. I understand information beyond patient evaluation, treatment and progress will not be disclosed with out a specific request for consent by the patient.


I understand the physical therapist makes to guarantee of treatment outcome.

Waiver of Liability

I understand there are certain inherent risks with physical therapy treatments because I will be asked to exert effort and perform activities with increasing levels of difficulty that could increase levels of pain or discomfort with a current or previous injury. I understand that it is my responsibility to stop treatment due to unmanageable discomfort or pain. I understand the physical therapist will take every precaution to ensure that I am protected from any potentially hazardous situation and that I will not be forced to perform any procedure or exercise that I do not wish to perform.

I hereby release the physical therapist from any responsibility or liability due to my participation in physical therapy. I am fully aware that I am participating in these sessions at my own risk and will not hold the physical therapist responsible in the event of my incurring an injury or exacerbating any previously existing conditions.

I agree the physical therapist shall not be liable or responsible for any injuries to me resulting from my participation in this physical therapy program, whether at home, at treatment facility, outdoors, residential or other facility.

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