FORM #: 1023
Patient ID: _________________
Physiomobility Health Group staff may leave phone messages at provided numbers for confirmation or changes to your scheduled appointments. (Please check the phone numbers below if you do not want us to leave phone messages)
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 HEALTH CONSENT: I understand that an internal assessment of the functioning of my pelvic floor may be deemed appropriate and there may bean 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.
We, at Physiomobility are here to provide you with thevery best care and attention. Weunderstand that unforeseen events and emergencies occur in everyone’s lives. Last minute cancellations and no-shows affectour ability to provide an outstanding experience to all of our patients. In consideration for our therapists’ time, wehave adopted the following policy.
If for any reason you have to cancel or re-schedule yourappointment with us, we require that you call or email the clinic 48 hours or 2business days in advance to inform us of the change. This will allow us to reschedule yourappointment and open the time slot for patients on the waiting list. A cancellation/no-show fee in the full amountof the booked missed appointment will otherwise be charged.
Please write Patient/Guardian full name below which serves as electronic signature.
Primary reason for Consultation:
Please check all boxes that apply to you:
Please check all current activities and activity goals appropriately:
Allergies (Please check all boxes that apply to you)
Medications/Creams (Please list below)