Policy Form

Payment policy: Payment is due at the time of the physical therapy session. Payment is $100 per session and can be paid via cash, check, credit card, HSA card, or Venmo. Please note that a bank fee of 0.04% will be added to payments made via card. An itemized, coded receipt will be emailed to you following your session which you can use for HSA/FSA reimbursement and/or to try to obtain reimbursement from your health insurance company. Points North Sports & Regenerative PT cannot guarantee that you will receive reimbursement from your health insurance company.

Consent: I consent to be treated for the injury/illness for which I have consulted Kathleen Doehla, DPT PT, within the physical therapist’s scope of practice.

"*" indicates required fields

Release of Information:

I authorize Kathleen Doehla, DPT PT, to communicate directly regarding my care with my other healthcare providers, my insurance company, and the following individuals/organizations I have listed below. A complete copy of HIPAA compliance guidelines is available on request.**

Name*

First Last

Email*

Signature*

Date*

MM slash DD slash YYYY

Name

This field is for validation purposes and should be left unchanged.