lvphysio_Authorization_for

Authorization for Pelvic Health Physiotherapy Treatment
I____________________, hereby consent to the assessment and treatment of pelvic problems including bladder/bowel/sexual dysfunction. I understand this assessment typically includes an internal vaginal/rectal exam.*
I have been provided with understandable information on my diagnosis as known, the examination proposed and any risks involved with the examination.

Following the examination, I will be provided with understandable information on the physiotherapy treatment being suggested, the risks and benefits of treatment, any additional procedures which may be necessary and the cost of treatment and cancellation fees.

I do not have a demand pacemaker, surgical metal staples in the abdominal area, metal IUD, pre-existing urogenital infection nor known sexually communicable disease.

I have informed my therapist whether or not I am pregnant.

I understand that pre-cautionary measures are taken regarding infection.

This consent may be withdrawn at any time.

The client is free to bring an additional person to any and all treatment sessions.

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Authorization for Pelvic Health Physiotherapy Treatment