PART B

PART C

Informed Consent to Physiotherapy Assessment & Treatment
I give voluntary consent to participate in the physiotherapy assessments and treatment as it will be outlined by my therapist. I understand that this will involve my active participation and I will comply with the therapist's recommendations in order to enhance my recovery. I acknowledge that my therapist will provide me with information that is pertinent to my treatment, including the possible risks and side effects. These risks include but are not limited to redness, bruising, burns, re-injury, muscle sprains, strains and headache. I understand that the assessment and treatment services I undergo may be administered by the treating therapist or by trained support staff working under the supervision of the treating therapist. I understand that anytime during the course of treatment, I am responsible for my own actions.

PART D

Physiotherapy & Massage Therapy Fees
The purpose of this section is to clarify your financial responsibilities in relation to your treatment.

✔ The patient is responsible for the full payment of services at the time services are rendered.

✔ Depending on your policy, your extended health benefit plan(s) may cover some or all the treatment cost. We offer direct billing to most insurance plans. However, some plans may not allow direct billing. Direct billing is a courtesy payment option that is offered by some benefit providers. We will try to direct bill your provider where this is applicable. However, we do not have control over this. So please check with your benefits administrator for more information.

✔ In all cases, patients are responsible for the full payment at the time services are rendered. We accept Cash, Debit, Visa, MasterCard. Alberta Health Care does not cover physiotherapy services in our clinic.

✔ If you are attending treatment because of a motor vehicle accident, you must provide our office with all the relevant information (claim number, adjustor name, etc.) for us to process your claim.

✔ For Patients receiving treatments out of Protocol (Section B), If you have extended health benefit (EHB) coverage for the treatment you are receiving (Physio, massage), your EHB provider is the primary payer for your treatment. If there’s any portion of your payment not covered by your EHB, or if you have exhausted your EHB coverage for the year, then your Motor vehicle insurance coverage may cover the remaining portion. However, you acknowledge that your motor vehicle insurance may not approve direct billing for your treatments, in that situation you are primarily responsible for the payment of your treatment or the uncovered portion as at the day of the treatment.

I have read, understood and agreed to the fees and payment obligations as listed above.

Part E:

Clinic Policy
Privacy Policy: Zenith Physiotherapy and Wellness Clinic is committed to controlling and protecting the collection, use and disclosure of the personal information provided by its patients. Our policy is guided by the Canadian Standards Association Model Code, and synthesizes relevant material from the Protection of Personal Information Protection and Electronic Documents Act (PIPEDA), and Health Information Act (HIA A complete copy of Zenith Physiotherapy and Wellness Clinic Private Policy is available on our website at: www.zenithphysio.com

Appointments:

✔ We kindly ask that you please be on time for your appointment. Please give us a call if you are running late for your appointment.

✔ We highly advise you to book your appointments well in advance to help secure the best spots for your schedule and to ensure continuity of your treatment plan as advised by your therapist.

✔ Cancellation and rescheduling Policy: Our therapists are here to help you, we value the time scheduled for you.

When patients do not show up or cancel appointments at the last minute, it leaves a gap in the therapist’s schedule that could have been taken by other patients. Out of respect for our therapists’ time and to be able to offer the spots to other patients, We do require you to please provide us at least 24 hours notice if you would like to reschedule or cancel a scheduled appointment. The clinic will charge you a fee of $25.00 for each cancelled or missed appointment if you do not notify us at least 24 hours before your appointment time.

✔ If you cancel 3 consecutive appointments without the required 24 hrs notice or if you do not show up for 3 consecutive appointments, we will cancel all your future appointments to make room for other patients. You will only be able to make same day appointment booking in the future, subject to schedule availability.

✔ For WCB patients: If you miss several appointments without reason, we are obliged to notify WCB and you may be discharged for the missed appointment if you do not notify us prior to your appointment time.

Clothing and attire:

✔ Please wear/bring along clothing attire appropriate for treatment. No perfumes, strong body odors, or excessive scents

Safety:

✔ Children must be under adult supervisor and are not to play with any equipment

✔ Please notify your treating therapist of any change in your condition or anything you are unsure about

✔ Please call for assistance immediately if you are in any discomfort during your treatment

✔ If you have inhalers or nitro spray or other emergency medication, please have it with you at all times while in the clinic

Food and Drinks:

✔ No food or drinks are allowed inside the clinic at any time.

Telephone calls

✔ We kindly ask that you turn off or put your cell phones in silent mode to ensure a private and comfortable treatment environment.

Lost or Stolen Items:

✔ We are not responsible for any items lost or stolen while attending our facility

Reports/Work Notes:

✔ A fee will be charged for reports and / or work notes. Please see the front desk for further details

Work Injuries:

✔ If you are attending treatment because of a work injury, it is your responsibility to report your injury to your employer and to WCB.