Consent Form - Pelvic Floor

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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):

Janet YangKanako NishiharaMihaela Marica

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:

I consent to have assessment and follow up communications sent to my healthcare providers.

I have read the above consent and have had an opportunity to ask questions about its contents.

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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