"Direct Physical Therapy Treatment Services
You are receiving direct physical therapy treatment services from an individual who is a physical therapist licensed by the Physical Therapy Board of California.
Under California law, you may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits, whichever occurs first, after which time a physical therapist may continue providing you with physical therapy treatment services only after receiving, from a person holding a physician and surgeon's certificate issued by the Medical Board of California or by the Osteopathic Medical Board of California, or from a person holding a certificate to practice podiatric medicine from the Podiatric Medical Board of California and acting within their scope of practice, a dated signature on the physical therapist's plan of care indicating approval of the physical therapist's plan of care and that an in-person or telehealth patient examination and evaluation was conducted by the physician and surgeon or podiatrist.
Patient's Signature/Date"
Ca. Bus. and Prof. Code § 2620.1