Consent Form - Consultation

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CONSENT FORM

INFORMED CONSENT FOR CONSULTATION

Patient ID: __________________________

The purpose of this form is to obtain your consent for a consultation with a physiotherapist. The purpose of this consultation is to gain general knowledge about your condition and provide you with some guidance as to the possible causes and available treatment options or the necessity of a referral to your primary care physician.

Education and safety tips may be provided during the consultation. No treatment will be provided during this session and a full assessment would be required prior to initiating a treatment plan.

All existing confidentiality protections and handling of medical information applies to the collected information during this consultation.

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 name

Date