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INFORMED CONSENT FORM CHIROPODY
CHIROPODY CONSENT TO ASSESSMENT & TREATMENT
PATIENT INFORMATION

Patient ID: _________________

First NameYour First Name
Last NameYour Last Name
I hereby request and consent to Chiropody assessment and treatment. I give the Chiropodist permission to perform necessary examinations and assessments, as well as diagnostic procedures as may be deemed necessary, in order to provide me with the best quality foot care.
I understand and am informed that, as in all health care, in the practice of Chiropody there are some very slight risks to treatment, including, but not limited to pain, swelling and infection.
I understand that the chiropodist may charge fees for services NOT reimbursed by and/or in addition to, the OHIP schedule of benefits. I further understand that I may withdraw my consent and request to terminate or modify the treatment at any time.
Please read carefully and check the following:
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:
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. A full amount of the service fee will be charged for late cancellation/no show if you cancel the same day or if you do not show up for your appointment. Please note that this fee is not billable to insurance policy and remains your responsibility.
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

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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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