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INFORMED CONSENT FORM
ACUPUNCTURE CONSENT TO ASSESSMENT & TREATMENT
PATIENT INFORMATION

Patient ID: _________________

First NameYour First Name
Last NameYour Last Name
SUBSTITUTE DECISION MAKER (if any)
First Name (Decison Maker)Decision Maker First Name
Last Name (Decison Maker)Your Last Name
I or my substitute decision-maker consent to Physiomobility Health Group to collect, use and disclose my personal health information for the purpose of providing traditional Chinese medicine or acupuncture to me and for the related purposes set out in Physiomobility written Privacy Statement.
The personal health information that may be collected, used or disclosed by the Clinic may include the following, among other things:
● my birth date and contact information
● my health and my family health history
● my health status
● the health care I receive (including identifying my health care provider(s))
● my health number
● the identification of my substitute decision-maker, if any
● insurance or billing information relating to health care
I understand that there may be situations in which practitioners at Physiomobility will have to collect, use or disclose personal health information without my consent, but that they will only do this if permitted by law.
How My Information Will Be Used
I understand that my personal health information may be collected, used or disclosed for the following reasons:
● To provide me with traditional Chinese medicine or acupuncture services
● To obtain payment for services provided
● To assist insurance companies with insurance claims verification
● To seek advice for potential treatment options
● To provide or arrange health care in cases of emergencies
● To fulfill any obligations as mandated by law
Patient Access to Information
I understand that my personal health information is available to me for my review except in limited circumstances as permitted by law. I also understand that I can ask to have my personal health information corrected if I believe there is a mistake in the records, with some exceptions.
Acknowledgment
Please read carefully and check the following:
I understand that I can access my personal health information with some limited exceptions. I understand that I am not required to sign this form and that I can withdraw my consent at any time by contacting Physiomobility Health Group, but it may directly affect the services I can receive. My personal health information may still be collected, used or disclosed if permitted by law.
Additional Comments or Restrictions
Additional Comments or Restrictions (if any)
0 /
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
by Electronic Signature
By typing my name (Patient or Guardian's full name) below, I am electronically signing this consent form.
Patient or Guardian Full Name
Date
Witness Signature
Patient or Guardian Full Name
Date

Copy of this form?

If you would like to receive a copy of this signed consent form, please provide an email address below:

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Omicron Update-Modified State 2 Lockdown

AS ESSENTIAL HEALTHCARE PROVIDERS, WE REMAIN OPEN

FOR IN-CLINIC & VIRTUAL (ON-LINE) TREATMENTS

JANUARY  4th, 2022 UPDATE

Read our COVID-19 Health & Safety Standards and Procedures

physiomobility_healthgroup-logo-2021

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