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Katharine Hauge, PT Corp  303-319-8020

4150 Darley Ave #10, Boulder, CO 80305 
Katharine@katharinehaugePT.com CO lic #7122

Hello and I hope to meet you soon! Kindly sign this form and know that your safety as well as efficacious intervention are my utmost priorities. Anything I feel might help you during therapy is explained and always requires your consent. This is a collaboration and you should always feel you can ask me anything about the efficacy of treatment strategies.


Your Privacy and HIPPA

I am required to maintain your privacy including all records and discussions we have. When/if you give me your express permission to share with other providers, this shall be done and only in an effort to provide you with the best care. The other reasons your information would be disclosed is if required by law or in case of an emergency. Please understand that your privacy is extremely important to me. You may reach me by email, phone or the business address provided and you may communicate with the US Department of Health and Human Services if you feel your rights have been violated. You have a right to request any information I have about you and to request changes made to your file that you feel are incomplete or inaccurate.


Trigger Point Dry Needling (TDN) Consent  

Trigger Point Dry Needling involves placing a small needle into the muscle at the trigger point to cause the muscle to contract and then release, improving the flexibility of the muscle and decreasing the symptoms.

TDN is a valuable treatment for musculoskeletal pain. Like any treatment, there are possible complications. While these complications are rare in occurrence, they are real and must be considered prior to giving consent to treatment.

 

Risks:

Though unlikely, there are risks associated with this treatment. The most serious risk associated with TDN 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 and re-inflation of the lung. This is a rare complication and in skilled hands, should not be a concern.

Other risks may include bruising, infection and nerve injury. Please notify your provider if you have any conditions that can be transferred by blood. Bruising is a common occurrence and should not be a concern unless you are taking a blood thinner. As the needles are very small and do not have a cutting edge, the likelihood of any significant tissue trauma from TDN is unlikely. NO needling is appropriate if you have any known diseases or infection that can be transmitted through bodily fluids, known HIV or Hepatitis B, metal allergies, and in some cases, pregnancy.

 

Consent to treat with use of Class IV laser 

The Class IV laser is a very effective tool to speed up healing of acute or chronic injuries. It is often used in conjunction with movement of muscles and/or joints, depending on the practitioner’s assessment of the injury. There are specific protocols in implementing the laser and each practitioner has been trained and certified in its use. Please read below as it is our utmost priority to maintain safety while maximizing benefit of this modality.

The Class IV laser speeds up tissue healing by way of allowing increased production of a critical substance called ATP, provides a temporary increase in microcirculation, and decreases inflammation. Increased microcirculation can provide relief for many acute and chronic conditions. Laser therapy utilizes visible and invisible laser radiation. Appropriate eye protection is required at all times during treatment. During treatment, no one else is allowed inside the room without the designated eyewear.

Effects of treatment will continue for up to 18 hours. Individuals respond uniquely to treatment in that some will feel immediate relief after the first visit, while others will require several treatments, depending on the severity and chronicity of the condition.

Increased soreness may occur after your first laser session. This is a normal healing phenomenon known as retracing. Mild bruising may occur from the soft tissue manual therapy element of your treatment program.

You are required to complete the consent form prior to treatment to ensure that laser therapy is a viable option for you.


Red Light Therapy

Similar to the Class IV laser, this is light energy in the Infrared and Near infrared wavelengths proven to penetrate deeper tissues to promote cell repair. The correct dosage helps to power your cells to provide energy and for healing damaged tissue. Protective eyewear is required and the treatment lasts 10 minutes. While the laser is a focused beam, the Red Light is a broad spectrum light energy used best for larger areas (whole spine, whole hip and pelvis, lower extremities for diffuse neuropathy). This device doesn’t necessarily provide heat except that people can feel warmth from the LED lights near the skin surface. Over 5,000 published studies exist to show the benefits of Red Light Therapy. Some benefits can include better sleep, reduced musculoskeletal pain, reduced joint stiffness, improved mood, improved cognitive function, post workout recovery and weight loss.

Contraindications to this treatment include: pregnancy, those with heart conditions, those taking photosensitizing drugs. If any of the above apply to you, we will seek other safe and efficacious intervention during your PT visit.


Extracorporeal Pulse Activation Technology (EPAT)

This device uses a compressed air-operated ballistic pulse generator. Kinetic energy is produced and converted to sound energy. This energy is then transmitted into the tissue to be treated using a handheld device and the use of gel on the skin surface. Evidence shows this treatment can help speed up healing of a host of injuries including plantar fasciitis, Achilles tendonosis, tennis and golfer’s elbow (epicondylitis), rotator cuff tendonitis (including calcific tendonosis), patellar tendonitis, bursitis and others. The total treatment time is less than 20 minutes (not including other PT interventions, home exercises).

Contraindications to this treatment include: heart conditions, coagulation disorders including hemophilia, use of anticoagulants, thrombosis, tumors, pregnancy, cortisone up to 6 weeks before treatment, epiphyseal fusion areas in children. If any of the above apply to you, we will seek other safe and efficacious intervention during your PT visit.


Physical Therapy consent for treatment

Your signature here is confirmation that you agree to be evaluated and treated by Katharine Hauge, PT. This may include manual treatments of which I am very skilled, exercises, and modalities for pain and/or to hasten healing. By signing this you understand that there is no guarantee on outcomes and timeframes for your healing.


Today's Date: November 30, 2022

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
If any of the following relate to you, we will further discuss if this is a safe modality for you during your visit. Your safety is my first priority.
Currently pregnant
Heart condition(s)
Taking any photosensitive prone medications
Current or recent cancer (Absolute contraindication to use of laser)
Open wounds and/or bleeding
Are you and adolescent still potentially growing?
Have you had a cortisone injection in the area to be treated in the last 10 days?
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
If any of the following relate to you, we will further discuss if this is a safe modality for you during your visit. Your safety is my first priority.
Currently pregnant
Heart condition(s)
Taking any photosensitive prone medications
Current or recent cancer (Absolute contraindication to use of laser)
Open wounds and/or bleeding
Are you and adolescent still potentially growing?
Have you had a cortisone injection in the area to be treated in the last 10 days?
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
If any of the following relate to you, we will further discuss if this is a safe modality for you during your visit. Your safety is my first priority.
Currently pregnant
Heart condition(s)
Taking any photosensitive prone medications
Current or recent cancer (Absolute contraindication to use of laser)
Open wounds and/or bleeding
Are you and adolescent still potentially growing?
Have you had a cortisone injection in the area to be treated in the last 10 days?
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
If any of the following relate to you, we will further discuss if this is a safe modality for you during your visit. Your safety is my first priority.
Currently pregnant
Heart condition(s)
Taking any photosensitive prone medications
Current or recent cancer (Absolute contraindication to use of laser)
Open wounds and/or bleeding
Are you and adolescent still potentially growing?
Have you had a cortisone injection in the area to be treated in the last 10 days?
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
If any of the following relate to you, we will further discuss if this is a safe modality for you during your visit. Your safety is my first priority.
Currently pregnant
Heart condition(s)
Taking any photosensitive prone medications
Current or recent cancer (Absolute contraindication to use of laser)
Open wounds and/or bleeding
Are you and adolescent still potentially growing?
Have you had a cortisone injection in the area to be treated in the last 10 days?
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
If any of the following relate to you, we will further discuss if this is a safe modality for you during your visit. Your safety is my first priority.
Currently pregnant
Heart condition(s)
Taking any photosensitive prone medications
Current or recent cancer (Absolute contraindication to use of laser)
Open wounds and/or bleeding
Are you and adolescent still potentially growing?
Have you had a cortisone injection in the area to be treated in the last 10 days?
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
If any of the following relate to you, we will further discuss if this is a safe modality for you during your visit. Your safety is my first priority.
Currently pregnant
Heart condition(s)
Taking any photosensitive prone medications
Current or recent cancer (Absolute contraindication to use of laser)
Open wounds and/or bleeding
Are you and adolescent still potentially growing?
Have you had a cortisone injection in the area to be treated in the last 10 days?
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
If any of the following relate to you, we will further discuss if this is a safe modality for you during your visit. Your safety is my first priority.
Currently pregnant
Heart condition(s)
Taking any photosensitive prone medications
Current or recent cancer (Absolute contraindication to use of laser)
Open wounds and/or bleeding
Are you and adolescent still potentially growing?
Have you had a cortisone injection in the area to be treated in the last 10 days?
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
If any of the following relate to you, we will further discuss if this is a safe modality for you during your visit. Your safety is my first priority.
Currently pregnant
Heart condition(s)
Taking any photosensitive prone medications
Current or recent cancer (Absolute contraindication to use of laser)
Open wounds and/or bleeding
Are you and adolescent still potentially growing?
Have you had a cortisone injection in the area to be treated in the last 10 days?
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
If any of the following relate to you, we will further discuss if this is a safe modality for you during your visit. Your safety is my first priority.
Currently pregnant
Heart condition(s)
Taking any photosensitive prone medications
Current or recent cancer (Absolute contraindication to use of laser)
Open wounds and/or bleeding
Are you and adolescent still potentially growing?
Have you had a cortisone injection in the area to be treated in the last 10 days?
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
If any of the following relate to you, we will further discuss if this is a safe modality for you during your visit. Your safety is my first priority.
Currently pregnant
Heart condition(s)
Taking any photosensitive prone medications
Current or recent cancer (Absolute contraindication to use of laser)
Open wounds and/or bleeding
Are you and adolescent still potentially growing?
Have you had a cortisone injection in the area to be treated in the last 10 days?
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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