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INFORMED CONSENT FORM
ACUPUNCTURE CARE BY CHIROPRACTOR
PATIENT INFORMATION

Patient ID: _________________

First NameYour First Name
Last NameYour Last Name
It is important for you to consider the benefits and risks and alternatives to the acupuncture treatment offered by your chiropractor and to make an informed decision about proceeding with treatment.
Acupuncture involves the insertion of small sterilized needles into specific locations on the skin surface. Other procedures related to acupuncture include moxibustion, cupping and electroacupuncture.
BENEFITS
Acupuncture and procedures related to acupuncture have been demonstrated to be a safe and effective form of treatment for a range of conditions including musculoskeletal complaints and pain.
RISKS
The risks associated with acupuncture include minor bleeding and bruising, temporary pain and soreness, nausea, fainting, burns, infection, shock, convulsions, pneumothorax, perforation of internal organs, and stuck or bent needles.
Please inform the chiropractor if you:
● Have or develop any major health issues
● Are pregnant or actively trying to be
● Have been fitted for a pacemaker or other electrical implants
● Have a bleeding disorder or take anticoagulants
● Have damaged heart valves or have a high risk of infection
● Suffer from metal allergies
● Have had prosthetic implants
● Are Immune compromised
Only sterile single use disposable needles will be used. All acupuncture needles are properly disposed of after each and every treatment.
PREGNANCY
The use of certain acupuncture points and treatment techniques may not be recommended during pregnancy. Advise your chiropractor if you are pregnant or actively trying to be.
ALTERNATIVES
Alternatives to chiropractic treatment may include consulting other health professionals. Your chiropractor may also prescribe rest without treatment, or exercise with or without treatment.
QUESTIONS OR CONCERNS
You are encouraged to ask questions at any time regarding your assessment and treatment. Bring any concerns you have to the chiropractor’s attention. If you are not comfortable, you may stop treatment at any time.
PLEASE BE INVOLVED IN AND RESPONSIBLE FOR YOUR CARE. INFORM YOUR CHIROPRACTOR IMMEDIATELY OF ANY CHANGE IN YOUR CONDITION.
CANCELLATION or NO SHOW POLICY
We, at Physiomobility are here to provide you with the very best care and attention. We understand that unforeseen events and emergencies occur in everyone’s lives. Out of respect for both your practitioners and your fellow patients we ask that you do your very best to arrive on time and to notify us as early as possible in the event that you are unable to attend. Last minute cancellations and no-shows affect our ability to provide an outstanding experience to all of our patients.
In consideration for our therapists’ time, we have adopted the following policy:
If for any reason you have to cancel or re-schedule your appointment with us, we require a minimum of 24 hours notice for change or cancellation of any appointment. This will allow us to fill the available time slot with another patient who needs our services. Patients will be responsible for paying 50% OF THE APPOINTMENT FEE if you cancel the same day and THE FULL APPOINTMENT FEE if you do not show up for your appointment.
SIGN & SUBMIT AFTER DISCUSSING TREATMENT PLAN WITH YOUR CHIROPRACTOR
by Electronic Signature
DO NOT SIGN THIS FORM UNTIL YOU MEET WITH YOUR CHIROPRACTOR
I hereby acknowledge that I have discussed with the chiropractor the assessment of my condition and the treatment plan. I understand the nature of the treatment to be provided to me. I have considered the benefits and risks of treatment, as well as the alternatives to treatment.
By typing my name (Patient or Guardian's full name) below, I am electronically signing this form and consent to acupuncture treatment as proposed to me.
Patient or Guardian Full Name
Date
Chiropractor Signature
Chiropractor Full Name
Date

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WE ARE OPEN

AS ESSENTIAL HEALTHCARE PROVIDERS, WE REMAIN OPEN FOR IN-CLINIC TREATMENTS DURING THE PROVINCE WIDE EMERGENCY BREAK ANNOUNCED ON APRIL 01, 2021

Physiomobility continues to remain open and is not part of the lockdown. We continue to have rigorous disinfection policies and procedures in place to ensure the safety of our community and are open for patient in-person visits with all of our practitioners.

Virtual appointments are available and encouraged for those who are at a heightened risk of illness.

We remain focused on our quality of care & our continued commitment to helping our patients feel their best. For further assistance, you can contact us at 416-444-4800 during our opening hours. 

The Physiomobility Team