northkamloopsphysio_Patient

GILL PHYSIOTHERAPIST CORPORATION NORTH KAMLOOPS PHYSIOTHEARPY

550 Tranquille Road, Kamloops, BC V2B 3H4 Robinder Gill MPT, BPT (Registered Physiotherapist) Tele: (250) 376-1141 Fax: (250) 376-9050
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PATIENT CONSENT FORM • Private Clients
Our clinic is committed to ensure you receive quality informed care and that your privacy is protected. For the duration of your treatment we request you informed consent to:

Provide assessment and treatment services to you

Collect, use, and share any relevant clinical information in providing services to you.

CONSENT TO ASSESS AND TREAT

Treatment information: Physiotherapy treatment techniques recommended to you may include, but are not limited to, Manual techniques, spinal manipulation, therapeutic exercise, electrotherapeutic modalities, as well as other techniques and procedures your treating physiotherapist determines may improve your function. Your physiotherapist will explain the benefits, side effects and potential complications of each chosen technique before use.

Throughout your recovery program, any questions or concerns you may have about any recommended treatment must be shared with your physiotherapist immediately so they can explain the treatment rationale and/or modify your program appropriately. If at any time, you choose not to participate in the course of treatment, please tell your physiotherapist.
I, ___________________________, hereby freely consent to participate in the physical and functional assessment and recommended treatment program (based on my medical history, diagnosis, symptoms and assessment results) delivered by those authorized in this clinic, having been informed about the following:*
What to expect in the assessment and treatment?

Who will be performing the assessment and treatment,

The reasons why I should have the assessment/treatment,

The alternatives to having the treatment,

What might happen if I do not have the assessment/treatment and

Any potential risks and/or side effects for the assessment and recommended treatment.

I understand and agree with the criteria above and as such agree to participate in an assessment and treatment program. My consent is voluntary for the entire course of assessment and treatment for my present condition, commencing on the date indicated below. I understand that I may ask questions at any time, and that my consent may be withdrawn in writing at any time, except for actions already taken.

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GILL PHYSIOTHERAPIST CORPORATION NORTH KAMLOOPS PHYSIOTHEARPY

PATIENT CONSENT FORM • Private Clients