Consent Form - Massage & Acupuncture

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INFORMED CONSENT FORM

CONSENT TO ASSESSMENT & TREATMENT

Please check all that applies

MASSAGE THERAPYMEDICAL ACUPUNCTURE

PATIENT INFORMATION

Patient ID: _________________

First NameYour First Name

Last NameYour Last Name

I understand that my assessment and treatment at Physiomobility Health Group is performed by a Registered Massage Therapist and may include, but is not limited to:

Exercise prescription, manual therapy techniques (such as mobilizations, soft tissue release, Myofascial release and stretches) and therapeutic modalities such as heat, ice, therapeutic taping and cupping). Other treatment options include electro-acupuncture/acupuncture/dry needling that involves the insertion of disposable and sterile needles through the skin into targeted tissue structures.

I understand that the primary goals of my treatments are to help reduce my pain, improve my mobility, strength, endurance, my overall functioning and quality of life.

I understand that there are very small possibilities of risks or complications that may result from the above listed treatments. I do not expect the therapist to anticipate all the possible risks and complications. I rely on my therapists' judgment to make decisions based on my best interests. Potential small but possible risk factors may include:

Manual Therapy & Myofascial release: Joint and/or muscle soreness and slight bruising

Exercise Therapy: Joint and/or muscle soreness

Therapeutic Taping & Cupping: Minor skin irritations such as redness or rash

Electro/Acupuncture/Dry Needling: Minor soreness, bleeding, bruising, nausea, fainting, headache, and infection, possible perforation of internal organs and stimulation of labour in pregnant women.

I will immediately notify my therapist of any changes in my pregnancy or medical status.

I will have the opportunity to discuss with my therapist the nature and purpose of all my treatments and I accept the fact that there is no guarantee to the effectiveness of the treatment. I am aware that I may withdraw this consent and discontinue my treatment at any time.

I consent to the assessment and treatment offered to me by my registered massage therapist. I also Consent to the assessment and treatment of the following areas by the therapist if clinically indicated: breast, chest wall, gluteal, and upper inner thigh.

Please read carefully and check the following:

I consent that I have read all above and intend this consent to apply to all my present and future care at Physiomobility. I also consent that the health records collected by Physiomobility Health Group will be available to all health providers involved in my circle of care. (For more information about your health records please ask to view our Privacy Policy).

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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