Physiotherapy Consent Form


Please Read Carefully

NOTE TO CLIENT: We want your informed consent. This means we want you to understand the services we hope to provide to you the cost involved, and what we do with personal information we obtain about you. If you have questions on any of this, please ask.

I, the undersigned, hereby provide informed consent to the assessment and treatment plan prescribed by the attending Physiotherapist who examined me, assessed my condition and explained the treatment plan to me.

• My treatment plan may include and but not limited to manual techniques, therapeutic exercise, modalities, acupuncture, taping as well as other techniques and procedures my treating therapist determines may improve function.

• I understand that my treatment may change from time to time at my health professional’s discretion.

• I agree to provide you the relevant information regarding my condition. I understand that the treatments may be administered by the Physiotherapist or support personnel under the supervision of the physiotherapist.

• What to expect in the assessment and treatment. The reasons why I should have the assessment & treatment & what might happen if I do not have Assessment / Treatment. Any potential risk and side effects for the assessment & recommended treatment.

• I must inform this office of any other practitioner (other than physicians) that I am currently seeing.

• I must inform my physical therapist of any contagious or infectious condition that I might have. I understand that I need to express all my health concerns (both current and past to my therapist)

• I understand that discomfort may occur following treatment. The therapist will contact my physician should the presence of symptoms represents any potential risks. I understand that it is my responsibility to contact a therapist in the clinic should I experience any unusual symptoms following treatment.

• I understand that if any time I am not comfortable with, and / or do not understand the purpose of any treatment procedures I will ask the physiotherapist for further explanation/ information. I understand that I may stop the assessment or treatment procedure at any time, during or after a session.

• I understand that the clinic will send an initial assessment and follow-up report(s) as appropriate to the licensed practitioner who referred me to the clinic for treatment.

• I have read, understood, and had opportunity to discuss the Client Information form I have read and fully understand all the above information and give my permission to be assessed and / or treated at Goreway Physiotherapy and Rehabilitation Centre.

My signature below indicates my understanding of all the above information. I, hereby freely consent to participate in the physical and functional assessment and recommended treatment program delivered by those authorized in the clinic. If under 16 years of age, the following section of the consent form must be completed by a parent or guardian before treatment can be initiated: