Healthcare FT Vibe

Healthcare FT Vibe — Patient Intake and Informed Consent

Patient Information

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History & Screening

Current Medications (include dose and frequency):

Allergies (medication, food, environmental):

Screening Checklist — please check all that apply

FT Vibe Therapy — Description, Risks, Benefits, Alternatives

Description: FT Vibe Therapy is a clinician-supervised, instrument-assisted vibratory modality intended to reduce musculoskeletal pain, improve circulation, and facilitate soft tissue mobilization. The procedure consists of localized application of vibratory stimulation to the treatment area for a prescribed duration and intensity determined by the treating clinician.

Risks and Potential Complications: While many patients tolerate FT Vibe Therapy without adverse effects, there are known risks including, but not limited to, transient increased pain, bruising, skin irritation, nerve irritation, dizziness, and rarely, exacerbation of an existing condition. Patients with certain implants, bleeding disorders, or pregnancy may face increased risk. Serious complications are uncommon but may occur.

Benefits: Potential benefits include reduction of pain, improved range of motion, decreased muscle tension, and enhanced recovery. Benefits are not guaranteed and vary by patient condition and adherence to treatment recommendations.

Alternatives: Alternative options include observation, medication management, physical therapy without vibratory devices, manual therapy, injections, or surgical consultation depending on diagnosis. Patient may refuse FT Vibe Therapy and elect another course of care.

Consent, Authorization, and Release

I, the undersigned patient or legal guardian, authorize the provider and staff to perform FT Vibe Therapy as described above. I acknowledge that the clinician has explained the nature, anticipated benefits, material risks, and reasonable alternatives, and I have had the opportunity to ask questions which were answered to my satisfaction. I understand that no guarantee has been made as to the results of the treatment.

I release the treating provider and affiliated staff from liability for complications resulting directly from the procedure except for damages resulting from gross negligence or willful misconduct. I agree to follow provider instructions and to report any adverse symptoms promptly.

Right to Withdraw: I understand that I may withdraw consent at any time prior to or during treatment without affecting my right to future care or treatment.

HIPAA / Privacy Authorization

I acknowledge receipt of the provider's privacy practices and authorize the release of my protected health information to insurance carriers and other entities for billing, payment, and treatment purposes as necessary to process claims and provide coordinated care. This authorization permits the release of medical records pertinent to FT Vibe Therapy and related services.

If you wish to limit release of your records, specify restrictions here:

Acknowledgments

By signing below I acknowledge that I have read and understand the information contained in this form. I confirm that the answers I have provided are accurate to the best of my knowledge. I accept responsibility to notify the provider of any changes to my medical condition prior to receiving additional treatments.

Patient Initials:

Provider Notes (for clinical use)

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