Dr. Nathan Mayberry, PT, DPT, CMTPT
Dr Bryant Hayes, PT, DPT, CSCS
A Functional Approach to Health and Wellness
Chadwick Building
1119 Route 3 North
Gambrills, MD
(410)693-0280
WELCOME LETTER
Welcome to my practice, Mayberry Physiotherapy, L.L.C. Our mission is to provide the guidance, environment and expertise necessary to help you achieve your healthy living goals. Our objective is to enhance your ability to return to a pain-free and active lifestyle. We promote independence through education in proper body mechanics and movement, self-treatment instruction, enhancement of strength, improved flexibility, and postural awareness. We our dedicated to the comprehensive delivery of the highest quality of care utilizing a multifaceted approach for lasting results.
My practice, Mayberry Physiotherapy L.L.C. does not participate with insurance companies. As an out-of-network provider, treatment may still be a reimbursable service through your insurance carrier. Payment is required at time of service. As a courtesy, we will prepare a claim form, “Superbill”, at the completion of your visit. You can submit this to your insurance company. We recommend that you contact your insurance company in advance to determine your out-of-network benefits. You may also need a referral. The initial Consultation visit is $125 (60-75min). Subsequent visits are $100 (60min). All visits are one-on-one, uninterrupted sessions.
Cancellation Policy: Our time and yours is very valuable. You will receive an appointment confirmation 48 hours in advance. Please change or cancel yourappointment at this time. A cancellation of your appointment less than 24 hours prior will result in a payment of the full session fee. We appreciate your cooperation and courtesy.
Please note that email addresses and contact information will be used only to forward educational and non-health related materials. Your records are held in the utmost confidence.
Patient/Client: I,______, have read and understand the above policy. I hereby agree to pay this clinician directly for professional services rendered. I hereby authorize the attending therapist to release any information
concerning my examination or treatments to my insurance carrier or other medical professionals involved in my care.
Mayberry Physiotherapy, L.L.C.
INFORMED CONSENT for PHYSICAL THERAPY SERVICES
Physical Therapy is a patient care service that is provided in order to manage a wide variety of conditions. Services are provided to individuals of all ages regardless of gender, race, ethnicity, creed, national origin or disability.
The purpose of physical therapy is to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis and intervention by use of rehabilitative procedures to aid the patient in achieving their maximum potential within their capabilities and to accelerate convalescence and reduce the length of functional recovery. All procedures will be thoroughly explained to you before being performed.
Response to physical therapy varies from person to person; hence it is not possible to accurately predict your response to a specific modality, procedure or exercise protocol. Mayberry Physiotherapy LLC. does not guarantee what your reaction will be to a specific treatment, nor does it guarantee that the treatment will help resolve the condition you are seeking treatment for. Furthermore, there is a possibility that physical therapy treatment may result in aggravation of existing symptoms and may cause pain.
It is your right to decline any part of your treatment at any time before or during treatment. It is your right to ask your physical therapist about the treatment they have planned based on your individual history, diagnosis, symptoms and examination results. Consequently, it is your right to discuss the potential risks and benefits involved in your treatment.
I have read this consent form and understand the risks involved in physical therapy and agree to fully cooperate, participate in all physical therapy procedures and comply with the established plan of care.
Patient Name______Signature______Date______
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Trigger Point Dry Needling involves inserting a tiny monofilament needle in a muscle or muscles in order to release shortened bands of muscles and decrease trigger point activity. This can help resolve pain and muscle tension, and will promote healing. This is not traditional Chinese Acupuncture, but is instead a medical treatment that relies on a medical diagnosis to be effective. Your physical therapist trained by MyoPain Semianrs has met requirements needed to perform the services requested. All training was in accordance with requirements dictated by this facility and by the U.S. state of this practitioner’s licensure.
TDN is a valuable and effective treatment for musculoskeletal pain. Like any treatment, there are possible complications. While complications are rare in occurrence, they are real and must be considered prior to giving consent for treatment.
Risks: The most serious risk with FDN is accidental puncture of a lung (pneumothorax). If this were to occur, it may likely 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 puncture can require hospitalization and re-inflation of the lung. This is a rare complication, and in skilled hands it should not be a major concern. Other risks include injury to a blood vessel causing a bruise, infection, and/or nerve injury. Bruising is a common occurrence and should not be a concern.
Patient’s Consent: I understand that no guarantee or assurance has been made as to the results of this procedure and that it may not cure my condition. My therapist has also discussed with me the probability of success of this procedure, as well as the probability of serious side effects. Multiple treatment sessions may be required/needed, thus this consent will cover this treatment as well as consecutive treatments by this facility. I have read and fully understand this consent form and understand that I should not sign this form until all items, including my questions, have been explained or answered to my satisfaction. With my signature, I hereby consent to the performance of this procedure. I also consent to any measures necessary to correct complications which may result.
Procedure: I, ______, authorize ______to perform Functional Dry
Needling® for my diagnosis of ______.
Please answer the following questions:
Are you pregnant? Yes No Are you immunocompromised? Yes No Are you taking blood thinners? Yes No
DO NOT SIGN UNLESS YOU HAVE READ AND THOROUGHLY UNDERSTAND THIS FORM.
You have the right to withdraw consent for this procedure at any time before it is performed.
______
Patient or Authorized RepresentativeDate
Relationship to patient (if other than patient)______
Physical Therapist Affirmation: I have explained the procedure indicated above and its attendant risks and consequences to the patient who has indicated understanding thereof, and has consented to its performance.
Mayberry Physiotherapy, L.L.C.
PATIENT DEMOGRAPHICS SHEET
How did you hear about us? If referred, by whom? ______
Who is you primary care physician? ______
(Name)(Telephone, if possible)
First name/M.I./Last Name ______
Gender ______Marital Status______Age______Birthdate______
Primary Phone______Secondary Phone______
Email Address______
Preferred Complete Mailing Address ______
______
______
EMERGENCY CONTACT INFORMATION
Full Name ______
Relationship to Patient ______
Primary Phone ______
Mayberry Physiotherapy, L.L.C.
FUNCTIONAL ASSESSMENT INTAKE
Medical History
Check the corresponding boxes if you have had any of the following:
Diabetes / Rheumatic Fever / Heart MurmurHigh Blood Pressure / Migraines/Headaches / Osteoporosis
Circulatory problems / Lung Disease / Epilepsy/Seizures
Arthritis / Neurologic Problems / Cancer
Stroke / Heart Disease / Fractures
Kidney Disease / Liver Disease / Metal Implants
Other? Please explain ______
List any significant hospitalizations and/or surgical procedures, reasons and dates:
______
List any medications you are presently on: ______
______
Do you have any skin or medication allergies? ______
______
Is there a chance you might be pregnant at this time? No_____ Yes_____# of weeks_____
Mayberry Physiotherapy, L.L.C.
Please provide a brief history of your illness or symptoms for which you request
treatment:
______
Is your pain constant or intermittent? ______
Please rate the pain intensity on a scale of 0 to 10 (10 being the worst pain)
012345678910
How would you describe the pain?
Does the pain radiate? Where? ______
What makes it feel better? ______
What makes it feel worse? ______
______
Mayberry Physiotherapy, L.L.C.
FUNCTIONAL HISTORY
What is your occupation? ______
In general, your lifestyle is:12345
Inactive averageactive
Do you engage in regular exercise? ______Yes ______No
What type? ______
Do you have discomfort, shortness of breath or pain with exercise? ______
Do you currently see an MD for your current condition? ______Yes ______No
Do you presently see a chiropractor?______Yes ______No
Do you presently see any other PT/OT?______Yes ______No
What are some things currently going very well in your life? ______
______
What are some current areas of stress in your life? ______
______
What is the quality of your sleep? How many hours? And in what position(s)?
______
What are your goals for treatment? ______
______
______
SignatureDate