Returning Self Pay Patient Form

Step 1 of 6

16%
  • CONSENT FOR TREATMENT

  • I, the undersigned, do hereby agree and give my consent for Body Gears Physical Therapy to furnish medical care and treatment to myself or _________________, considered necessary and proper in diagnosing or treating my physical condition.
  • COST FOR YOUR APPOINTMENT

  • 20 Minutes = $75
    40 Minutes = $150
    60 Minutes = $200
    House Call = $350

    Missouri Client Costs:
    20 Minutes = $60
    40 Minutes = $120
    60 Minutes = $180
    House Call = $350


    Payment is due at the time services are rendered in the for of cash, check, or credit card. Please note, any checks returned as non-sufficient funds will incur a $25.00 fee.
  • CANCELLATION POLICY

  • Together, you and your therapist will set your treatment goals and time frames to complete these goals. It is important that you all attend schedule treatment sessions to achieve the best success. If you must cancel or change an appointment, we request that you give us 24-hour notice (business days only) prior to your scheduled appoint time by calling (877) 709-1090. For house call visits cancelled within 24 hours, a 100% cancel fee will apply as we cannot reschedule new patients with such short notice. For self-pay patients being seen in one of our clinics, a $25 cancellation fee will apply.
    I acknowledge that I have read and understand this cancellation policy.