hereby consent to assessment and treatment by a Registered Physiotherapist/ Registered Chiropractor/Registered Massage Therapist, or anyone working in this facility authorized by the Russett Rehabilitation and Wellness Clinic. I will have an opportunity to discuss with the attending registered practitioner the nature (frequency/duration of each session, length of program) and purpose/goals of the service, and of the treatments/procedures that I may receive. I will be advised of the risks and benefits. I understand that the results are not guaranteed.
CONSENT OF PERSONAL INFORMATION
Iunderstand that to provide me with the appropriate goods and services, Russett Rehabilitation and Wellness will collect some personal information about me. This includes home and work telephone number, address, date of birth, and if applicable SIN number, WSIB claim number, Extended Health Benefits Information, Automobile Insurance Information, Casualty or LTD Insurance 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 agree to Russett Rehabilitation and Wellness Clinic collecting, using and disclosing personal information about me as set out above and in Russett Rehabilitation and Wellness Clinic's Privacy Policy.