You understand that Evolv Physical Therapy & Performance will maintain your privacy to the highest standards and may use or disclose your personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment.

You have read and fully understand that you may request in writing that Evolv Physical Therapy & Performance restricts how your private information is used or disclosed to carry out treatment, payment or healthcare operations. You also understand that Evolv Physical Therapy & Performance is not required to agree to your requested restrictions unless agreed upon in writing.

You understand that you may revoke this consent in writing at any time, except to the extent that Evolv Physical Therapy & Performance has taken action relying on this consent.