INFORMED CONSENT FOR PHYSIOTHERAPY

I hereby request and consent to the service of Physiotherapy treatment and other physiotherapy procedures, including various modalities , mobilizations , soft tissues release , stretching and strengthening exercise on me by the registered physiotherapist.

I understand that I will have an opportunity to discuss with the physiotherapists and/or with other office or clinic personnel, the nature of treatment, its advantages and disadvantages and risk factors associated to the same. I understand the results may not be guaranteed.

I am informed that, as in all health care, in the practice of physiotherapy there are some very slight risks to treatment, including, but not limited to, muscle strains and sprains, bruising, light headed or dizziness, and tenderness. I do not expect the physiotherapist to be able to anticipate and explain all risks and complications and I wish to rely on the Physiotherapist to exercise judgment during the course of the treatment which the Physiotherapist feels at the time, based upon the facts then known, and is in my best interests.

I understand that I will be draped at all times and the areas undraped will be secure to insure there is no indecent exposure. If undraping my gluteal region is significant in the treatment, I do understand that it is part of the therapy.

I am informed that I have the right to withdraw the consent and terminate the treatment at any time.

I am aware there are further alternatives offered such as chiropractic, acupuncture, reflexology, and massage therapy etc.

I am aware the Physiotherapy treatment is NOT covered by OHIP; however, I or my extended health insurance will be payable for the treatment and consultation charge.

I have read the above consent. I have also had an opportunity to ask questions about the treatment to the Physiotherapist and the consent is given by signing below, I agree to the above-named procedures. I intended this consent form to cover the entire course for the treatment for my present condition and for any future condition(s) for which I seek treatment.