Osteopathic Manual Therapy Consent Form Patient (or Guardian) First & Last Name(Required) First Last What is the primary complaint that you are seeking Osteopathic Manual Therapy for?(Required)Do you presently have or ever had any of the following: Dizziness Earaches Sinus problems Eczema/Psoriasis Chest pains Chronic cough TMJ/Jaw pain Swollen/Stiff Joint Rheumatoid Arthritis Osteoarthritis Heart Palpitation Poor circulation Pins/needles in extremities Cold hands/feet Sensitive skin Varicose veins Phlebitis Poor digestion/indigestion IBS Constipation Diarrhoea Kidney/Bladder Liver/Gallbladder Fatigue Hormone imbalance Thyroid trouble Vertigo Hearing loss Sleep disorder Memory loss Anaemia Other Other WomenMenstruation Painful Heavy Light Normal Irregular Absent Pregnant Number of childrenMenopause Pre Active Post Breast tissue Swollen Painful Cystic Abnormal sensation Other Other Previous Medical History, including trauma, car accident, accidents:Family Medical History Cancer Diabetes Hi/lo Blood pressure Heart Disease Other Other Social History Tobacco Coffee Drugs Alcohol Other Other Informed Consent for Assessment and Treatment (Osteophatic Manual Treatment)Manual osteopathy is widely recognized as one of the safest drug-free, non-invasive therapies available for the treatment of neuromusculoskeletal and joint complaints. Treatments may include manual therapies where the health practitioner places his hands on your body. Although manual osteopathy has an excellent safety record, no health treatment is completely free of potential adverse effects. The risks associated with manual osteopathy, however, are minimal. Many patients feel immediate relief following manual osteopathy treatment, but some may experience mild soreness or aching, just as they do after some form of exercises or massage. Current literature shows that minor discomfort or soreness following soft tissue therapy typically fades within 24hours. Many techniques will involve contact between your body and the practitioner’s body. Body and hand contact may include areas of your chest wall, pelvic floor, and pubic bones. At times, the practitioner may ask you to remove some items of clothing in order to facilitate assessment/treatment. If you do not feel comfortable with any part of the treatment, please inform your practitioner immediately. The techniques can be discontinued or modified as per consent. Informed Consent for Assessment and Treatment (Osteopathic Manual Treatment)(Required) I have informed the Osteopath of all my known physical conditions, mental conditions, and medications and I will keep the practitioner updated on any changes. I understand that there are possible risks and benefits of osteopathy and that they have been explained to me regarding my individual treatment plan and accept responsibility of informing my practitioner if I do not understand any aspect of the risks and benefits. I understand that osteopathy is not a substitute for medical treatment and/or medications and that it is recommended that I work concurrently with my primary caregiver for any conditions I have. I am aware that diagnosing conditions is not part of the osteopath’s scope of practice. Cancellation of AppointmentPalermo + Physiotherapy & Wellness requires a minimum of 24 hours notice for any appointment cancellations. Should you give less than 24 hours notice, a $45.00 cancellation charge may be charged. Your appointment time has been reserved specifically for you. Should you book an appointment and not to attend, you are responsible to pay for the entire cost of the appointment .Payment InformationI understand that payments for services at Palermo + Physiotherapy and Wellness Centre are my responsibility after every service is received. If my claim is to be submitted to an outside agency for payment, and for any reason the third-party payer, such as insurance or employer denies and/or refuses to pay for the full amount I am billed, I am responsible for payment. Osteopathic Manual Therapy Fees: Initial Assessment: $119.00 Follow-Up Visit: $85.00Patient (or Guardian) Signature:(Required)Date(Required) Month Day Year PhoneThis field is for validation purposes and should be left unchanged.
