Physiotherapy Consent Form Patient (or Guardian) First & Last Name(Required) First Last What is the primary complaint that you are seeking Physiotherapy for?(Required)Informed Consent for Assessment and Treatment (Physiotherapy)Informed Consent for Assessment and Treatment (Physiotherapy)(Required) During your initial visit, the Physiotherapist will explain your diagnosis and discuss treatment recommendations. The success of your treatment is dependent upon your participation in the treatment plan agreed upon with your Physiotherapist. Physiotherapy treatment techniques may include but are not limited to manual techniques (joint mobilizations, joint manipulations, soft tissue techniques), electrotherapeutic modalities, acupuncture and exercise. Throughout your treatment, should you have any questions or concerns about any recommended treatment, inform the therapist immediately so rationale for treatments and/or adjustments can be made.I understand that after the treatment I may experience mild side effects like; muscle soreness, pain, tenderness.I hereby consent to the rendering of evaluations, treatments and / or services as communicated by the Physiotherapist. My consent is voluntary, and I intend this consent to cover the entire course of assessment/treatment commencing on the date indicated below. I understand that I may ask questions at any time regarding the assessment and treatment and that this consent may be withdrawn at any time. Cancellation of AppointmentCancellation of Appointment(Required) Palermo + 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 InformationPayment Information(Required) I 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.Physiotherapy Fees:Initial Assessment: $110.00Follow-Up Visit: $75.00 Patient (or Guardian) Signature:(Required)Date(Required) Month Day Year NameThis field is for validation purposes and should be left unchanged.
