Patient Intake Form

Patient Information

Let's start with the basics. Fields marked * are required.

First Name *

Last Name *

Date of Birth *

Referring Physician

Address

Email *

Cell Phone *

Age

Height

Weight

Reason for Treatment

What brings you in? *

Do you have a diagnosis of Lipedema / Lymphedema?

Yes No

If yes, when did symptoms begin?

Puberty Pregnancy Other

Medical History

Check all that apply — this helps Dr. Grace prepare safely for your visit.

Medications, Tests & Background

Include anything relevant to your care.

Medications & Supplements (dose / frequency)

Medication Allergies

Diagnostic tests completed

X-rays MRI CT-Scan Lymphoscintigraphy

Test findings

List of surgeries

Falls in the past 12 months

Prior Treatment & Occupation

Have you received lymphatic or orthopedic treatment before?

Yes No

For what condition?

Result of therapy

Occupation

Currently working?

Yes No

Pain Assessment & Goals

Tell us how you're feeling and what you hope to achieve.

Informed Consent for Physical Therapy

Please read and acknowledge below.

The purpose of physical therapy is to treat disease, injury and disability through examination, evaluation, diagnosis, prognosis, and intervention using rehabilitative procedures, mobilization, massage, exercises, and physical agents to help you reach your maximum potential and shorten functional recovery. All procedures will be explained before you are asked to perform them. Because responses vary from person to person, your specific response to any modality, procedure, or exercise cannot be accurately predicted.

Level Up Rehabilitation Services, LLC does not guarantee your reaction to a specific treatment, nor that treatment will resolve your condition. Physical therapy treatment may aggravate existing symptoms and may cause pain or injury.

Please communicate with your treating physical therapist throughout treatment. You have the right to decline any part of your treatment at any time, before or during treatment, if you feel discomfort, pain, or have unresolved concerns. You have the right to ask about the planned treatment based on your history, diagnosis, symptoms, and examination, and to discuss the potential risks and benefits.

By acknowledging below, I confirm I have read this consent, understand the risks involved in physical therapy, agree to fully cooperate and participate in all procedures, comply with the plan of care, and authorize the release of my medical information to appropriate third parties.

I have read and agree to the Informed Consent for Physical Therapy. *

Full Name (e-signature) *

Date *

Dry Needling Consent

Required only if dry needling may be part of your care. Please review the risks and screening questions.

Dry needling (DN) is a skilled technique performed by a physical therapist using a single-use, sterile filiform needle inserted through the skin or underlying tissue to affect pain, movement, and impairment. As with any treatment, complications are possible. Though rare, they are real and must be considered before consenting.

Most serious risk: pneumothorax

The most serious risk is accidental puncture of a lung (pneumothorax). If this occurred it may require a chest x-ray and possibly no further treatment; shortness of breath could last days to weeks. A more severe lung puncture, while rare, may require hospitalization.

Other risks may include bruising, infection, or nerve injury. Bruising is common and not a cause for concern. The monofilament needles are very small with no cutting edge, so significant tissue trauma is unlikely.

Screening questions

Are you taking blood thinners?

YesNo

Are you, or could you be, pregnant?

YesNo

Any problems or concerns with your immune system?

YesNo

Any known disease/infection transmissible through bodily fluids?

YesNo

I understand no guarantees have been made about success. I understand multiple sessions may be required and that this consent covers this and subsequent treatments. My questions have been answered, and I may withdraw consent at any time. I authorize the performance of dry needling and any measures necessary to correct resulting complications.

I authorize the performance of Dry Needling and agree to the above. *

Full Name (e-signature) *

Date *

Relationship to patient (if not self)

Telemedicine Disclosure & Consent

Applies to any video/telehealth visits.

I understand my provider may wish to conduct a telemedicine visit using video conferencing, and that this differs from an in-person visit because we will not be in the same room.

I understand there are potential risks including interruptions, unauthorized access, and technical difficulties, and that either party may discontinue the visit if the connection is inadequate.

I understand my health information may be shared for scheduling and billing, and that others may be present to operate equipment — all of whom maintain confidentiality. I will be informed of their presence and may: (1) omit personally sensitive details; (2) ask non-medical personnel to leave; and/or (3) terminate the visit at any time.

Alternatives to a telemedicine visit have been explained to me. In an emergency, the consulting specialist's responsibility is to advise my local practitioner and concludes when the connection ends. I understand I must show photo ID each session, as will my clinician. I have had the opportunity to ask questions, which were answered to my satisfaction.

I have read and understand this disclosure, including its risks and benefits, and consent to telemedicine visits. *

Full Name (e-signature) *

Date *

Cancellation & No-Show Policy

Please review and acknowledge.

Situation	Fee / Consequence
No-Show	Full session fee charged to card on file
Cancellation < 24 hours	$50.00 late cancellation fee
Cancellation ≥ 24 hours	No charge — thank you for the courtesy

No-show: failing to attend with no prior notice results in the full visit fee charged to the card on file. A written appeal may be submitted within 7 days for documented medical emergencies.

Late cancellation (<24h): incurs a $50.00 fee regardless of reason, except documented emergencies reviewed case-by-case. This fee is not covered by insurance and is your direct responsibility. To avoid it, cancel at least 24 hours ahead.

To cancel or reschedule: online at levelupptdoc.com, phone (703) 637-8252, or fax (571) 617-0044.

By scheduling, you authorize Level Up Rehabilitation Services, LLC to charge applicable fees to your payment method on file. Fees are non-refundable except at management's discretion.

I have read, understand, and agree to the Cancellation & No-Show Policy, and authorize charges to my payment method on file. *

Full Name (e-signature) *

Date *

HIPAA Acknowledgement

Your privacy rights and how your health information is used.

I understand I have certain privacy rights regarding my protected health information (PHI) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). By acknowledging this consent, I authorize use and disclosure of my PHI to carry out:

• Treatment (including by other providers involved in my care)
• Obtaining payment from third-party payers (e.g., my insurance)
• The day-to-day healthcare operations of the practice

I have been informed of and given the right to review and obtain a copy of the Notice of Privacy Practices, which more fully describes uses and disclosures of my PHI and my rights. I understand the practice may change the notice terms and that I may request the most current copy at any time.

I understand I may request restrictions on use/disclosure for treatment, payment, and operations, that the practice need not agree, but if it does it is bound to comply. I understand I may revoke this consent in writing at any time, though disclosures made before revocation are unaffected.

I acknowledge and consent to the HIPAA terms above. *

Full Name (e-signature) *

Date *

Photography / AI / Media Authorization Optional

This section is entirely voluntary and does not affect your treatment. Select only what you're comfortable with.

Photography & Image Use

I grant voluntary consent to photograph, video, or capture images of me for the purposes I select below. Any identifying image is treated as PHI and used only for consented purposes.

Clinical Documentation & Treatment Records — stored as PHI in my record; no external disclosure without separate authorization. Interdisciplinary & Referring Provider Communication — shared with treating clinicians for care coordination. Educational & Professional Training — used for clinical education or case studies. Social Media & Marketing Publication — Instagram, Facebook, LinkedIn, or practice website. Voluntary; does not affect treatment.

If you selected social media/marketing, please acknowledge:

My name/likeness may appear publicly and cannot be fully retracted once published. My health information will not be disclosed in captions without my explicit permission. I may request removal; re-publication by third parties cannot be controlled.

Body area(s) I do NOT consent to photograph

Additional restrictions

Clinical Dictation & AI-Assisted Documentation

I consent to voice dictation and AI-assisted transcription used solely to create and maintain accurate clinical documentation in my EMR, with provider review and authentication of all AI-generated notes, HIPAA-compliant vendors under BAAs, minimum-necessary safeguards, and record retention for at least six years.

I acknowledge audio/voice capture during or after sessions for documentation. I acknowledge AI-assisted transcription, reviewed by my provider before finalization. I consent to clinical dictation and AI-assisted documentation as described.

Full Name (e-signature)

Date

Refusal or withdrawal of consent in this section will NOT affect the quality of your clinical care. You may revoke in writing at any time except where action has already been taken.

Review & Submit

Confirm everything looks right, then submit. Your packet goes directly to Dr. Grace.

Consent Status

Please email me a copy of my completed forms.

By submitting, you confirm the information provided is accurate and complete to the best of your knowledge, and that your typed names serve as your electronic signatures.

REQUEST YOUR PRIVATE CONSULTATION

THANK YOU!

Patient Information

Medical History

Medications, Tests & Background

Pain Assessment & Goals

Informed Consent for Physical Therapy

Dry Needling Consent

Most serious risk: pneumothorax

Telemedicine Disclosure & Consent

Cancellation & No-Show Policy

HIPAA Acknowledgement

Photography / AI / Media Authorization Optional

Review & Submit

Thank you — your packet is complete.