TELEHEALTH INFORMED CONSENT – PHYSICAL THERAPY (NEW YORK)

I consent to receive telehealth physical therapy services provided by Dr. Mary Ann Adornato, PT, DPT. Telehealth includes evaluation, therapeutic exercise instruction, movement analysis, and clinical consultation delivered via secure electronic communication.

RISKS

Potential risks include technology failure, limitations in assessment without hands-on contact, privacy risks if not in a secure location, and emergency response limitations. Telehealth may not be appropriate for all conditions.

EMERGENCY PROTOCOL

Telehealth is not appropriate for medical emergencies. In an emergency, I will call 911. I agree to provide my physical location at the start of each session.

HIPAA & PRIVACY

I acknowledge receipt of the Notice of Privacy Practices and understand my Protected Health Information will be handled in accordance with HIPAA and New York State law.