Prescribing doctor's name: Address:

Acceptance as Patient:

The taking of a history and the conducting of a physical examination are not considered treatment, but are part of the process of information gathering so that the practitioner can determine whether I am an appropriate patient for their services. I understand and agree that the practitioners of Russett Rehabilitation and Wellness Clinic have the right to refuse or accept me as a patient at any time before treatment begins if deemed that I am not an appropriate patient for their services.

Please check off any conditions that you have experienced.

We are committed to protecting your privacy and ensuring the confidentiality of your personal health information. The types of personal health information we collect may include your name, date of birth, health history, OHIP number and records of the care provided to you. We collect, use and disclose personal health information for the following purposes:

To provide physiotherapy, chiropractic, massage therapy and pedorthic services to our clients

To conduct quality improvement and risk management activities

To obtain payment for services provided (from you, OHIP, WSIB, auto insurance, your private insurer or others)

To comply with our regulatory obligations to College of Physiotherapists of Ontario, College of Chiropractors of Ontario, Massage therapy, pedorthic

To teach students and to provide continuing education to our staff

To advise clients about special events or opportunities (but we will always obtain express consent to do so)

For other purposes permitted by law

We will collect, use and disclose only as much personal health information as is needed to achieve these purposes. You can withhold or withdraw your consent to the collection, use or disclosure of your personal health information by contacting (details below)

Access to Health Records

You have the right to seek access to your health records that we keep and to ask us to correct a record if you believe it is inaccurate or incomplete. Please contact us for more information.

Questions or Concerns?

If you have questions or want to make a complaint about out privacy practices, please contact: LeeAnn Russett, Health Information Custodian. You also have the right to complain to the Information and Privacy Commissioner of Ontario or the address below if you have concerns about our privacy practices or how your personal health information has been handled:

Information and Privacy Commissioner/Ontario
2 Bloor Street East, Suite 1400, Toronto, Ontario M4W 1A8 Telephone: Toronto Area (416/local 905): (416) 326-3333, Long Distance: 1(800) 387-0073 (within Ontario)

TDD/TTY: (416) 325-7539 FAX: (416) 325-9195

www.ipc.on.ca

I will have an opportunity to discuss with the attending registered practitioner the reasons for and nature of the treatment proposed. I was advised of the benefits, risks, side effects of the proposed treatment, the alternatives to having the treatment and what would happen if I do not have the treatment. I understand and have no further questions. My consent is voluntary.

CONSENT OF PERSONAL INFORMATION

I have been provided the opportunity to review the Russett Rehabilitation and Wellness Clinic's Privacy Policy about the collection, use and disclosure of personal information, steps taken to protect the information and my right to review my personal information. I understand how the Privacy Policy applies to me. I have been given a chance to ask any questions about the Privacy Policies and they have been answered to my satisfaction. I understand that I can withdraw consent at any time by contacting LeeAnn Russett.

I agree to Russett Rehabilitation and Wellness Clinic collecting, using and disclosing personal health information about me as set out above and in Russett Rehabilitation and Wellness Clinic's Privacy Policy.

Dear Patient;

Thank you for choosing Russett Rehabilitation and Wellness Clinic as your treatment facility. It is necessary that you be advised of and agree to the payment policy for our services before you begin treatment.

We accept Cash, Visa, MasterCard, Debit and Cheques as forms of payments.

PAYMENT DUE AT THE COMPLETION OF EACH APPOINMENT.

For treatment covered by WSIB or Motor Vehicle Insurance, you acknowledge that you are fully responsible for completing and submitting all necessary paperwork to the insurer to ensure timely and complete payment for rehabilitation services. If a claim is denied you will be responsible for the treatment bill. We encourage you to bring in your paperwork if you have questions regarding its completion.

If you plan to submit your receipts to an extended health insurer, please review your plan to ensure that you understand your coverage.

We kindly ask for 24 hour notice for any cancelled appointments. Cancellations received without 24 hour notice will charged 50% of service fee. Failure to provide any notice the full service fee will be charged.

Please call the clinic if unable to make an appointment and leave a message on our 24 hour answering machine, in order for us to fill that appointment.

We do understand that there are unforeseen circumstances (weather, illness, medical emergencies) these appointments will not be charged if not given 24 hours notice. In these circumstances we do request you call the clinic as soon as possible SO we can attempt to fill that appointment.

Ihave read the above information and understand and agree with the payment policy.