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INFORMED CONSENT FORM
CONSENT TO ASSESSMENT & TREATMENT
Please check all that applies
PATIENT INFORMATION

Patient ID: _________________

First NameYour First Name
Last NameYour Last Name
I understand that assessment and treatment at Physiomobility Health Group is performed by a registered physiotherapist and may include, but is not limited to:
Exercise prescription, manual therapy techniques (such as mobilizations, manipulations, soft tissue release and stretches) and therapeutic modalities (such as heat, ice, electrical stimulation, ultrasound, laser and shock wave therapy, cupping and therapeutic taping). Other treatment options include 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: Joint and/or muscle soreness
Massage Therapy: Muscle soreness or 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.
Please read carefully and check the following:
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

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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