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INFORMED CONSENT FORM
PELVIC FLOOR CONSENT TO ASSESSMENT & TREATMENT
PATIENT INFORMATION

Patient ID: _________________

First NameYour First Name
Last NameYour Last Name
I hereby consent to assessment and/or treatment given by registered physiotherapist(s):
I understand that my treatments may include treatments for therapeutic, preventative, diagnostic and/or other health related purposes. I understand that I may rescind my consent at any time.
PELVIC FLOOR CONSENT: I understand that an internal assessment of the functioning of my pelvic floor may be deemed appropriate and there may be an internal component (vaginal/rectal) to the assessment and/or treatments. When this is the case, this will be discussed in detail with me before proceeding and I may grant or refuse consent.
Please read carefully and check the followings:
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?

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