I confirm that the information I provided is true and accurate to the best of my knowledge. I authorize Atom Physical Therapy P.C. to evaluate and treat me for my current medical condition and assign applicable medical benefits directly to Atom Physical Therapy P.C.

I understand that my care is subject to the clinic’s privacy practices and policies. I will receive information describing those policies and may ask staff for another copy or clarification. Treatment cannot begin until all required policies and consents have been acknowledged.