INFORMED CONSENT FOR TREATMENT
As you have consulted with STRIDES OF CNT LLC (“Strides“) and have decided to receive Sports Medicine services from Michael Derecola, ATC,
IT IS IMPORTANT THAT YOU, THE PATIENT, READ THIS CONSENT FORM CAREFULLY AND OBTAIN ANSWERS TO ANY QUESTIONS THAT YOU MAY HAVE.
Sports Medicine involves the use of several modalities of evaluation and treatment. Accordingly, at Strides of CNY, we use a variety of procedures and treatments to help us to try and improve your physical function. As with all forms of medical treatment, there are benefits and risks involved with sports medicine.
As patient responses to a specific form of treatment can vary widely from patient to patient, it is not always possible to predict responses to a specific form of treatment. Therefore, Michael Derecola, ATC cannot guarantee any reaction or success to a given form of treatment. There is also a risk that your treatment may result in pain, injury, or may aggregative a previous condition.
You have the right to inquire as to the form of treatment based upon your history, diagnosis, symptoms, and testing result. You may also discuss with your Certified Athletic Trainer the potential risks and benefits of a specific treatment and possible alternative treatments. You have the right to decline any portion of treatment at any time or during your treatment sessions. Your Certified Athletic Trainer stands ready to answer any questions you may have regarding a given course of treatment, type of exercise, associated risks, and possible alternatives. This Consent Form is based upon your informed decision to participate in the proposed treatment plan for Sports Medicine services as explained to you by the Certified Athletic Trainer identified below.
I hereby authorize and consent for Michael Derecola, ATC and/or any physical, assistant or students in training under the direction of the Certified Athletic Trainer as selected by him/her, to provide sports medicine services in accordance with the proposed treatment plan which has been explained to me in a way that I can understand. I understand that some of the sports medicine services provided to me at Strides of CNY LLC may be performed by an Certified Athletic Trainer/Physical Therapist other than the Certified Athletic Trainer/Physical Therapist as identified in this Consent Form.
The above Certified Athletic Trainer has discussed with me in words that I can understand, my diagnosis, conditions, the reasons for and benefits of the proposed plan of sports medicine services, the reasonable likelihood of its success, the possible consequences of not choosing this plan, the possible risks associated with this plan, and possible alternatives and risk associated with those alternatives, as well as my goals of recovery and any potential problems that might arise during treatment. I understand and have discussed with the above Certified Athletic Trainer that my condition could also be treated by alternative procedures or therapies, but I have decided not to undergo these alternative treatments at this time. I understand that there are risks associated with sports medicine which may include the aggravation of previous injuries or the worsening of current conditions, as well as injuries common to the performance of exercise.
I understand that I am giving this consent with the understanding that any treatment/procedure involves some risks and hazards, and that no guarantees have been made to me as to any treatments or examinations by Michael Derecola or the Certified Athletic Trainer/Physical Therapist and supporting staff. The approximate duration of my treatment has been discussed with me by the Certified Athletic Trainer indicated above.
CERTIFIED ATHLETIC TRAINER DECLARATION
Prior to presenting this Consent Form, I have discussed with the Patient and/or the Patient’s Guardian (if applicable) the planned examination/assessment; evaluation, diagnosis, and prognosis/plan; the intervention/treatment to be provided; the nature of the proposed treatment; the benefits reasonably expected from the proposed treatment, together with the material risks and dangers of the proposed treatment; treatment alternatives, as well as the risks and benefits of such alternatives; and that Michael Derecola, ATC cannot provide any form of guaranty. I have explained the contents of this Consent Form to the Patient and/or the Patient’s Guardian (if applicable) and have answered all of the Patient’s and/or the Patient’s Guardian’s (if applicable) questions in a language the Patient and/or the Patient’s Guardian (if applicable) understands and all questions have been answered in a satisfactory manner. To the best of my knowledge, the Patient and/or the Patient’s Guardian (if applicable) has and/or have been adequately informed and has and/or have consented to this treatment/plan of care. As you have consulted with STRIDES OF CNT LLC (“Strides“) and have decided to receive Sports Medicine services from Michael Derecola, ATC.
Certified Athletic Trainer Signature
I HEREBY CERTIFY THAT I HAVE READ THIS FORM (OR HAVE HAD IT READ TO ME) AND FULLY UNDERSTAND THE ABOVE CONSENT. I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS, AND ALL OF MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION. I DO NOT DESIRE ANY FURTHER EXPLANATION AND UNDERSTAND AND ACKNOWLEDGE THAT COMPLICATIONS CAN RESULT.
I CERTIFY THAT I HAVE HAD SATISFACTORY OPPORTUNITY TO DISCUSS MY CONDITION, DIAGNOSIS, AND TREATMENT WITH THE ABOVE ATHHLETIC TRAINER WHO HAS FULLY EXPLAINED THE NATURE AND EXPECTED BENEFITS, ALTERNATIVES AND RISKS INVOLVED IN THE PROPOSED PLAN FOR PHYSICAL THERAPY SERVICES I HAVE CHOSEN AND ALL OF MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION. I HAVE BEEN GIVEN ENOUGH INFORMATION AND FACTS UPON WHICH TO MAKE AN INFORMED DECISION ABOUT CHOSING THE PROPOSED PLAN FOR PHYSICAL THERAPY SERVICES, THE ALTERNATIVES, AND RISKS IN MY OWN LANGUAGE AND IN A MANNER THAT I CAN UNDERSTAND. I ACCEPT THAT NO GUARANTEES HAVE BEEN MADE TO ME CONCERNING THE PROPOSED PLAN FOR SPORTS MEDICINE SERVICES. I UNDERSTAND THAT THE PROPOSED PLAN FOR SPORTS MEDICINE SERVICES MAY NOT IMPROVE MY CONDITION AND MAY, IN FACT, WORSEN IT.
I CERTIFY THAT I HAVE DISCLOSED COMPLETELY AND TRUTHFULLY ALL OF MY MEDICAL HISTORY; MY COMPLAINTS AND/OR AILMENTS; AND MY USE OF ALL PRESCRIPTION AND NON-PRESCRIPTION DRUGS, VITAMINS, MINERALS, AND DIETARY SUPPLEMENTS.
I HAVE CAREFULLY READ AND FULLY UNDERSTAND THIS CONSENT FORM AND I VOLUNTARILY AUTHORIZE AND CONSENT TO THE PROPOSED PLAN FOR SPORTS MEDICINE SERVICES. DO NOT SIGN THE BELOW UNLESS YOU HAVE READ AND THROUGLY UNDERSTAND THIS CONSENT FORM: