Physical Therapy Treatment Plan Agreement
Patient Information
Patient Name
Date of Birth
Contact Number
Email Address
Address
Provider Information
Therapist Name
Clinic Name
Diagnosis & Medical History
Diagnosis
Relevant Medical History
Treatment Plan
Goals
Proposed Interventions / Procedures
Number of Sessions
Frequency (e.g., x/week)
Home Exercise Program Instructions
Consent & Agreement
By signing below, I acknowledge that I have reviewed and agree to the outlined treatment plan. I understand the purpose, risks, benefits, and alternatives of the physical therapy plan as explained to me.
Patient Signature
Date
Therapist Signature
Date