INFORMED CONSENT and PRIVACY POLICY

INFORMED CONSENT and PRIVACY POLICY

PLEASE READ CAREFULLY AND THOROUGHLY

I hereby request and consent to Physiotherapy Assessment and treatment, Acupuncture, Massage Therapy and other related procedures.

I have discussed with the therapist the nature and purpose of Physiotherapy, Massage Therapy, and other related procedures. I understand that results will vary depending on the individual and the extent of their condition.

I understand and am informed that, as in all health care, there are some risks to treatment, which, if applicable, will be discussed before the treatment. I wish to rely on the therapist to exercise judgment during the course of the procedure based upon facts then known.

Fee Schedule for Massage Therapy: (PLUS HST)

30 min - $42.48; 45 min -$60.18; 60 min - $75.22; 90 min - $110.62; 50 min aqua massage-$100.00

Physiotherapy: Assessment $100.00; Physiotherapy Treatment - $60.00

**The clinic charges a 50% cancellation fee for a missed appointment with less than twenty-four (24) hours’ notice. An additional charge of $25.00 for NSF cheques.

Sharpe Physiotherapy collects, uses and discloses health information according to the Personal Health Information Privacy Act. Sharpe Physiotherapy may disclose personal and health information to you, your Physician and other health care providers under your consent.

Sharpe Physiotherapy is committed to take steps to protect your personal health information from theft, loss and unauthorized access, copying, modifications, use, disclosure and disposal and to protecting your privacy and only using your personal health information for the purposes you consent.

I agree to Sharpe Physiotherapy collecting, using and disclosing personal information about me. I authorize release of my personal information to and from Sharpe Physiotherapy to the following stated below:

Dr:______

I have read the above authorization and indicate my consent valid unless or until I withdraw. I have the opportunity to read the above and questions regarding its content

Signature:______Date: ______Print Name______

PTO….>

Waiver and Release

Name; ______Telephone:______

Address ______Email: ______

Male ______Female ______Age: ______

Activity Name: Physiotherapy/Acupuncture ______Aqua therapy______Massage Therapy ______Craniosacral Massage Therapy ______Reflexology______Nia ______Yoga ______

I am not aware of any health condition I may have that would suggest to me that I should not participate in this activity. I have not been advised to avoid participating in this activity by a qualified health care provider. I understand that Sharpe Physiotherapy may not allow me to participate in this activity if it determines in its sole discretion that may be incapable of meeting the physical or mental requirements of this activity. I assume full responsibility for any injury, loss of personal property and any expense I may incur by participating in this activity. I understand and agree that I am releasing not only Sharpe Physiotherapy, but also its, employees and contractors

I understand that Sharpe Physiotherapy uses this Waiver and Release for activities instructed and conducted by its employees and/or contractors s. In consideration of permitting me to participate in this activity, on behalf of myself and my family, executors, administrators, heirs, next of kin, successors, and assigns, I waive, release, discharge, and promise to indemnify and not sue Sharpe Physiotherapy. , its employees and/or contractors for all claims, including those arising from Sharpe Physiotherapy’s employees, Contractors or my own negligence, for any liabilities arising at law or in equity from my death, disability, personal injury, property damage, or property theft, and any other claims for damages I may have now or in the future, related directly or indirectly to my participation in this activity and my travelling to and from this activity. I understand that this Waiver and Release will be used against me in any proceeding in which I may claim any kind against Sharpe Physiotherapy and/or its employees or agents.

I consent to receive emergency medical treatment if I am injured during the activity. In case of emergency, please contact; ______. I give permission for me to be transported to any medical facility or hospital and I authorize any qualified health care provider to give medical care to me.

I acknowledge that I have read this document and that I understand the words written in it. I have been advised of the potential dangers incidental to participating in this activity and/or receiving instruction for it.

Signature of Participant: ______Date:______

Sharpe Physiotherapy protects your privacy. The Personal information provided by you in this Waiver and Release is collected and used by Sharpe Physiotherapy for the purpose of processing your request to participate in this activity and to provide your information about our programs, services, and activities. Please contact us by telephone at 705-778-5427 if you do not wish to receive this information or if you wish to receive a copy of our Privacy Policy. PTO..>