INFORMED CONSENT & POLICY

Informed consent is obtained to ensure that you are aware of the possible side effects/risks due to treatment and also that you are aware of your rights as a patient of the clinic.

The initial session comprises of an examination consisting of postural analysis, physical exam, muscle testing and orthopaedic/neurological examination.

During the treatment certain methods may be applied such as heat, ice, electrotherapy, vibration therapy, massage therapy and ultrasound. As part of your ongoing treatment, certain devices/procedures may be used such as weight machines, stretching, whole body vibration and tense machine.

The slight health risks of some treatments include but are not limited to: aggravation of pre-existing symptoms, pain, bruising, muscle spasms, strains, disk injuries and burns.

I also recognize the following:

  • No part of my treatment is covered by OHIP and that I am solely responsible for payment of services rendered at the end of the appointment.
  • I am aware that 48 hours notice must be given for all cancelled appointments, otherwise a cancellation fee of 40$ for Kizhi and 50$ for Shirodhara will be applied.

  • I also confirm that I can accept or reject this care of my own free will and choice.  I accept full responsibility for any fees incurred during care and treatment.  If I choose to suspend or terminate my care and treatment, all fees for professional services rendered to me will be immediately due and payable.
  • I understand that the doctor reserves the right to determine which cases fall outside his scope of practice, in which event the appropriate referral will be recommended.
  • I understand that for the best results, treatment program compliance is required.  However, I am aware that results are not guaranteed.
  • I understand that all information provided during my visit is strictly confidential. Information may only be released upon my written consent or requested by law.
  • I consent to the treatments offered and recommended to me.  I intend this consent to apply to all my present and future care.

    Medical History

    Full Name
    Date of Birth
    Gender
    Contact Information
    Phone Number
    Email Address
    Street Address
    Apartment / Unit
    City
    Province / State
    Postal / ZIP Code
    Medical History
    Heart problems?
    Chest pain / shortness of breath?
    Asthma / TB / lung issues?
    Persistent cough?
    Recent viral infection?
    Diabetes?
    High blood pressure?
    Cancer history?
    Epilepsy / seizures?
    Skin condition?
    Allergies?
    On medication?
    Use orthotics/braces?
    Hospitalized in last 12 months?
    Had surgery?
    If yes, specify surgery
    History of fractures?
    Accident / WSIB injury?
    Musculoskeletal issues?
    If yes, specify problem
    Pregnant?
    Signature
    Date Signed

    Consent