Physical Therapy Plan-of-Care Agreement

This agreement sets out the terms of an ongoing course of physical therapy between the clinic ("Provider") and the patient ("Client"). It becomes effective only when BOTH parties have signed below. The Provider completes the plan and fee details and signs first, then shares this document with the Client for review and countersignature — either in-app, or by printing, signing, and uploading a scanned copy.

Section 1 — Parties & Episode of Care

Provider (clinic name):

Treating therapist:

Client (full legal name):

Client contact email:

Episode start date:

Estimated episode length:

Section 2 — Plan of Care & Frequency

The Provider will deliver the following plan of care during this episode:

The plan of care is a clinical estimate and may be adjusted as the Client progresses. Any material change will be discussed with the Client before it is applied.

I have read and understand the plan of care and visit frequency in this section.

Section 3 — Fees & Payment

Fees are payable at the time of service unless otherwise agreed in writing. Where insurance or a third party is billed, the Client remains responsible for any balance not covered.

I have read and agree to the fees and payment terms in this section.

Section 4 — Attendance & Cancellation

Consistent attendance is important to your recovery. Please give at least 24 hours’ notice to reschedule or cancel a visit. Late cancellations and missed visits may be charged the fee set out in Section 3, and repeated missed visits may lead the Provider to pause or close the episode of care.

I understand the attendance expectations and the cancellation notice period.

Section 5 — Consent to Treatment & Risks

Physical therapy may include manual techniques, therapeutic exercise, modalities, and education. As with any physical treatment, there are potential risks such as temporary soreness, fatigue, or, rarely, aggravation of symptoms. The Client may ask questions, decline any technique, or stop treatment at any time. The Client should promptly report any new or worsening symptoms to the treating therapist.

Please note any conditions, medications, or precautions the therapist should be aware of:

I consent to the physical therapy treatment described and understand its potential risks and benefits.

Section 6 — Privacy & Records

The Provider keeps clinical records confidential and shares them only as needed for your care, for billing, or as required by law. With your consent, the Provider may communicate with your referring physician and other members of your care team. Records are retained in line with applicable regulations.

I have read and agree to the privacy and records terms in this section.

I consent to the Provider communicating with my referring physician and care team about my treatment.

Section 7 — General Acknowledgments

I have read and understood each section of this agreement.

I have had the opportunity to ask questions and seek independent advice.

I consent to electronic signatures having the same legal effect as handwritten signatures.

I am authorized to enter into this agreement on behalf of the party named above.

Section 8 — Signatures

Provider — printed name:

Date:

Client — printed name:

Date:

Optional — upload a countersigned scan of this agreement:

This template is provided for reference only and does not constitute legal or medical advice. Consult qualified professionals before relying on this document.