Telehealth Informed Consent

Last updated: November 4, 2026

Before your first visit with Internet Physical Therapy (a service of Dr. Kareem F. Samhouri Fitness LLC), you will be asked to read and sign this consent in Jane, our patient portal. It is posted here so you can read it ahead of time. If you haven’t signed it before your first visit, your Physical Therapist will go through it with you at the start and record your verbal consent in your chart.

What telehealth physical therapy is

Telehealth means your Physical Therapist evaluates and treats you over a live, secure video connection instead of in person. Your Physical Therapist is currently Dr. Kareem Samhouri, PT, DPT. During visits your Physical Therapist may ask about your health, watch how you move, guide you through tests and exercises, teach you a home program, and review your progress. Notes and reports from your visits become part of your medical record, which you can see and get a copy of.

• At your first visit, we’ll confirm who you are, and you can ask to see your Physical Therapist’s license.
• We’ll tell you if anyone else is in the room with your Physical Therapist, and you can tell us if you’d like someone with you.
• Neither of us records a visit (video, audio or screenshots) without asking and getting the other’s permission first.
• We never use images or recordings that identify you for teaching or marketing without your separate written permission.

Benefits and limits

Telehealth lets you get care from home without travel or waiting rooms. It also has limits: your Physical Therapist cannot touch you, use hands-on techniques, or examine you in the same way as in person, so some problems may be harder to assess. In-person physical therapy is always an alternative you can choose instead. If your Physical Therapist decides that video visits aren’t safe or right for you, we will tell you and recommend in-person care.

Risks

• The video connection may fail or be poor quality, which may delay or end a visit.
• Information from a video visit may not be enough to make a full assessment.
• Exercise carries a risk of injury, including falls, soreness or a flare-up of symptoms.
• Although we use secure technology designed to meet HIPAA requirements, no electronic system is completely free from privacy risks.

Where you are during each visit

Your Physical Therapist must be licensed in the state where you are physically located at the time of each visit, currently Arizona and Pennsylvania. At the start of each visit you agree to confirm where you are, including your address, so that help can be sent if there is an emergency. If you’re not in a state where your Physical Therapist is licensed, the visit will be rescheduled.

Safety during visits

• Use a private, well-lit space with room to move, a stable chair, and nothing you could trip over.
• If you are at risk of falling, have another adult nearby during visits.
• Tell your Physical Therapist right away if you feel pain, dizziness, chest discomfort or shortness of breath, and stop the activity.
• Keep your phone nearby. If the video drops, rejoin from your reminder email or your Jane account (your reminder may also include a backup link). If that doesn’t work, we’ll call you.
• In an emergency, call 911. If your Physical Therapist believes you are in danger, they may contact emergency services where you are, or your emergency contact, and give them your location.

Pennsylvania

If you’ll be in Pennsylvania during your visits, state law requires a referral for physical therapy treatment. We need one before your first visit from a physician, physician assistant or certified registered nurse practitioner, or from a dentist or podiatrist for a condition they treat.

Your rights

• Taking part in telehealth is your choice. You may stop at any time, and choosing not to use telehealth will not affect your right to care elsewhere.
• Your health information is protected as described in our Notice of Privacy Practices, and you can get a copy of your records.
• You may ask questions about your care and this consent at any time.

Your consent

By signing this consent in Jane, you confirm that you have read and understood it, that you have had the chance to ask questions, and that you agree to receive physical therapy by telehealth from Internet Physical Therapy. You also confirm that the information you give us is accurate and that you will tell us about changes in your health or location.

Questions

Dr. Kareem F. Samhouri Fitness LLC
Internet Physical Therapy
53 Pinon Ct, Sedona, AZ 86336
Phone: 855-375-2733
Email: support@internetphysicaltherapy.com