Consent Form - Chiropody - Physiomobility

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INFORMED CONSENT FORM

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:

I have read the above consent. I have had the opportunity to ask questions about its content, and by signing below I agree to treatment by Chiropodist. I intend for this consent form to apply to the entire course of my treatment, including today and any other future visit.

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

Copy of this form?

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