Dear Patient,

Welcome to our practice - we're so glad you've chosen us to be part of your recovery journey. At Sports & Ortho Physical Therapy, everything we do is rooted in our commitment to Restore Empower Uplift.

When you come to us, you can expect:

- Hands-on care combined with functional exercise - every session is crafted to restore movement, strength, and confidence in ways that matter to your real life.

- 75-90 minute sessions - giving you the best of both worlds: one-on-one manual therapy followed by comprehensive functional exercise.

- Whole-body approach - we don't just treat symptoms, we evaluate and address your entire kinetic chain, ensuring long-term success and resilience.

- Consistent care team - you'll see no more than two therapists throughout your plan of care. This ensures excellent communication, flexibility with scheduling, and seamless teamwork between you and

- Collaboration and connection - communication and teamwork are the heart of our practice, both within our team and with you as our partner in health.

As an independent private practice specializing in the kinetic chain, we believe you'll quickly see how we are different from traditional physical therapy settings. Our survival depends on the trust and satisfaction of our patients - not big hospital systems or corporate marketing. The most powerful way you can support us is through your referrals, word of mouth, and online reviews. If your experience here helps you restore, empower, and uplift your life, we'd be grateful if you help us reach others who need the same.

Thank you for trusting us with your care. We look forward to working together to restore your health, empower your movement, and uplift your life.

With gratitude,

Dahlia Fahmy, Owner & Founder
and The Sports & Ortho Team

Consent to Treat: I authorize PT evaluation & treatment.

PLEASE INITIAL EACH POLICY AND SIGN BELOW. PLEASE READ CAREFULLY AND IN ITS ENTIRETY

HIPAA

I understand that under HIPAA, I have certain rights to privacy regarding my protected health information. This information can and will be used to conduct, plan, and direct my treatment, obtain payment, and conduct normal healthcare operations.

RESPONSIBILITIES

I understand treatment may occur in an open area. If I prefer privacy, I must inform my therapist so accommodations can be made.

CANCELLATIONS AND ATTENDANCE

All cancellations must be made at least 24 hours prior. A $60 charge will be assessed for no-shows or late cancellations. Two courtesy late cancellations are allowed at no charge.

MEDICAL NECESSITY AND AUTHORIZATIONS

I am fully responsible for all services rendered, regardless of insurance coverage. Benefit verification is a courtesy and not a guarantee of payment. If I provide inaccurate or incomplete information and visits are denied, I am responsible for all costs.

CONSENT TO TREAT

I consent to Sports & Ortho Physical Therapy providing evaluation and treatment as deemed necessary and proper.

BENEFIT ASSIGNMENT

I assign all medical benefits to Sports & Ortho Physical Therapy and authorize release of information necessary to secure payment.

WORKER'S COMP PATIENTS ONLY

Missed or canceled appointments will be reported to my worker's compensation case manager as attendance is required.

BCBS CTY (CITY OF CHICAGO) PATIENTS ONLY

I understand that I am allowed 10 physical therapy visits per year without requiring a script or authorization. It is my responsibility to provide accurate information on prior visits; if I do not and visits are denied, I remain responsible for payment.

VIDEO/PICTURE/SOCIAL MEDIA RELEASE

I authorize Sports & Ortho to use photos, video, audio, or articles for media/marketing. This is voluntary and may be revoked at any time. Refusal does not affect my care. I will not be compensated. 

POLICY AGREEMENT & FINANCIAL RESPONSIBILITY

 I attest that I have read and agree to the above policies, authorize Sports & Ortho to collect payments (including via credit card on file), and understand I am financially responsible for any balance owed. As a courtesy, we will verify benefits and submit claims on your behalf; however, verification of benefits is not a guarantee of payment. You are ultimately financially responsible for all services rendered, regardless of insurance coverage, reimbursement, or benefit limitations.
 
You authorize the clinic to charge your card on file for:
1. All patient responsibility balances after insurance claims are processed (adjudicated)
2. Balances not paid at time of service
3. Denied or partially paid claims
4. Missed appointment / late cancellation fees, per clinic policy
5. Any outstanding balance after reasonable billing attempts

You will receive notice of charges via statement, email, or receipt..

Thank you for choosing private practice and entrusting us with your care. We are honored to serve you.

Sports and Ortho Physical Therapy app is now available for download, and it offers a wealth of exercises and stretches specifically tailored to help with recovery and performance. Here’s how you can download and install the app on your phone.

1. Open the App Store on your phone

2. Search for “RecoverX”

3. Tap on the app listed as “Sports and Ortho: RecoverX” and then tap the “get”button to download and install

4. Once installed, please sign up with your personal email address and use access code: Sports&Ortho2024

5. Once entered, you will receive an email that you must verify before using

Please remember we are here to support you. If you have any questions or need assistance with the app, please do not hesitate to ask a staff member. Your well-being is our top priority, and we are committed to providing you with the tools you need to stay strong and healthy.

Dry Needling (DN) involves inserting a tiny monofilament needle into symptomatic tissue with the intent to reduce pain, increase circulation and improve function of the neuromusculoskeletal system. DN is not traditional Chinese Acupuncture, but instead is based on neurology, physiology and western medical principles. DN is a valuable treatment for musculoskeletal pain; however, like any treatment there are possible complications. While these complications are rare in occurrence, they are real and must be considered prior to giving your consent for dry needling treatment.

Risks of the procedure:

The most serious risk associated with DN is accidental puncture of a lung (pneumothorax If this were to occur, it may likely only require a chest x-ray and no further treatment. The symptoms of shortness of breath may last for several days to weeks. A more severe lung puncture can require hospitalization. This is a rare complication and in skilled hands should not be a concern.

Other risks may include bruising, infection and/or nerve injury. It should be noted that bruising is a common occurrence and should not be a concern. The monofilament needles are very small and do not have a cutting edge; the likelihood of any significant tissue trauma from DN is unlikely. There are other conditions that require consideration so please answer the following questions:

 

I have read and fully understand this consent form and attest that no guarantees have been made on the success of this procedure related to my condition. I am aware that multiple treatment sessions may be required, thus this consent will cover this treatment as well as subsequent treatments by this facility. All of my questions, related to the procedure and possible risks, were answered to my satisfaction. My signature below represents my consent to the performance of dry needling and my consent to any measures necessary to correct complications, which may result. I am aware I can withdraw my consent at any time.