the patient/parent/guardian, hereby agree to the following:

Authorization for Rehabilitation: I consent to assessment and treatment at Radiant Physiotherapy and I acknowledge that the information regarding my diagnosis, treatment and/or any further information needed for my care may be obtained.

I acknowledge that the service I am about to receive may have risks involved.

I authorize Radiant Physiotherapy to provide medical information (status and progress) to my medical practitioner, insurance company, WCB, lawyer, employer or their representatives as needed for my treatment.

I agree to pay any outstanding fees incurred for therapy.

By providing my email, I consent to receive emails from Radiant Physiotherapy i.e. appointment reminder, invoicing, newslettersetc. By providing my email

Radiant Physiotherapy has a 24 hour cancellation policy which states that appointments cancelled less than 24 hour in advance will be charged a $25.00 per missed appointment. I understand that I will be charged for failing to attend my appointment or canceling without 24 HOURS NOTICE. I understand the fee for each missed appointment or late

cancellation is $25 or $50 for pelvic floor physiotherapy and is due prior to my next scheduled appointment.

WHILE WE DO OUR BEST TO FACILITATE COURTESY REMINDER EMAILS IN REASONABLE TIME, PATIENTS ARE RESPONSIBLE FOR THE MANAGEMENT OF THEIR APPOINTMENTS. FAILURE TO PROVIDE ADEQUATE NOTICE FOR A CANCELLATION WILL RESULT IN A FEE REGARDLESS IF A REMINDER WAS RECEIVED OR NOT.