Examples: Referred by a doctor, referred by friend/colleague/family, advertising (brochures, banner, etc.), by chance/walk in, by employee staff, internet search, returning patient
Please Read Carefully I, the undersigned, do hereby give my voluntary consent for the administration of Physiotherapy deemed appropriate by my treating Physiotherapist. I understand that Physiotherapy treatments may include an individualized exercise prescription and various forms of manual therapy techniques such as mobilization, manipulation, soft tissue release and stretches. Treatments may also include modalities such as heat, ice, therapeutic taping, ultrasound, laser, TENS, interferential current, shock wave and electrical muscular stimulation. Other treatment options include acupuncture/dry needling that involves the insertion of single use, sterile, disposable needles through the skin, into the underlying muscles. I understand that the primary goals of Physiotherapy treatments are to help reduce my pain and improve my mobility, strength, endurance, function and quality of life. I understand that there are very small possibilities of risks or complications that may result from the above listed treatments. I do not expect the Physiotherapist to anticipate all the possible risks and complications. I wish to rely on the Physiotherapist to exercise proper judgment during the course of treatment to make decisions based upon my best interest. Potential small but possible risk factors: Manual Therapy: Joint and/or muscle soreness Exercise Therapy: Joint and/or muscle soreness Electrical modalities: Minor skin irritations such as redness or a rash Therapeutic Taping: Minor skin irritations such as redness or a rash Acupuncture/Dry needling: Minor soreness, bleeding or bruising, nausea, fainting, infection, shock convulsions, possible perforation of internal organs, stuck or bend needles, and fetal distress in pregnant women I will immediately notify the Physiotherapist of any changes in my pregnancy or medical status. I will have the opportunity to discuss with my Physiotherapist the nature and purposes of all my treatments. I accept the fact that there is no guarantee of the effectiveness of the treatment. I am aware that I may withdraw this consent and discontinue treatment at any time. I consent to the Physiotherapy treatments offered or recommended to me by my Physiotherapist(s). I intend this consent to apply to all my present and future Physiotherapy care.
Please briefly write in your words the primary reason for your physiotherapy consult: (e.g. back & leg pain)
If you selected allergies in the previous question, please list them below:
Have you had any surgeries? If so, please list them:
Please tell us what your (3) primary goals are or what you wish to achieve with your treatments: (e.g. return to playing tennis 3x a week, return to my full-time work, be able to walk for 30 minutes, eliminate headaches, etc.)
