Welcome to Grand River Sports Medicine Centre Inc. (GRSM Inc.) Your safety and health and that of our GRSM staff is of the utmost importance to us. To open our clinic as safely as possible, we have put strict processes in place to minimize the transmission of the COVID-19 virus. If you have any concerns, please do not hesitate to ask.

We want you to understand and consent to the services we provide to you, the costs involved and what we do with personal information we obtain about you.

Consent for Assessment & Treatment

A registered Physiotherapist will complete your assessment. The physiotherapy assessment typically involves a detailed history-taking as well as a specific physical examination which may include such measures as joint range of motion, strength and functional testing. These results will be analyzed to develop a treatment plan that is specific to your condition(s).
Physiotherapy treatment techniques may include, but are not limited to: manual therapy techniques, spinal manipulation, electrotherapeutic and exercise modalities, acupuncture (including IMS). A number of these treatments may be recommended during your program. To ensure the benefits, side effects, and potential complications of each chosen treatment are understood, it is the policy of GRSM that the treatment technique be explained to you by your physiotherapist before use, as your participation in all aspects of the program is imperative to success.
Throughout your program, if you have any questions or concerns about any recommended treatment you must inform your therapist immediately so they can explain the treatment rationale and/or modify your program appropriately. If at any time you choose not to participate in the program or any portion of it, you must inform your physiotherapist immediately.
I have read, understood and agree to the above statements and as such agree to participate in an assessment and treatment program at GRSM. I understand that for the duration of my treatment, my consent may be withdrawn at any time and that I must inform my physiotherapist.

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I also understand that although GRSM has put strict procedures in place to reduce the potential transmission of the COVID-19 virus, there are inherent risks in choosing to enter the clinic.
Note: if the client is under the age of 18 a parent or guardian must sign for them.

By signing this form, you agree to our treatment.

Consent for the Cost of Our Services 

You will be given a current Fee Schedule at the time you sign this Consent Form. By signing this form, you agree:

• To pay for all services at the time they are rendered/provided
• If you do not pay for a service at the time it is received, you agree to pay interest on any outstanding balance at the rate of 24% per annum (2% per month) and, on default, to pay all costs of recovering the debt, including legal and/or agent costs; To assist in the recovery of any unpaid account, by signing below, you consent to GRSM Inc. and its agents obtaining personal information about you from your insurance provider, credit reporting agencies and others.”
• To provide 24 hours notice when canceling an appointment. Because your appointment time is reserved exclusively for you and our professionals cannot use this time to see other patients, if you do not provide 24 hours notice of cancellation, you agree to pay our standard fee for the missed appointment, as if you had attended.

Consent for Personal Information

Grand River Sports Medicine Centre will collect some personal information about you (e.g. home address, telephone numbers, health history etc.) in order to provide you with rehabilitation services and products. Upon request, you will be given a copy of our Privacy Policy about the collection, use and disclosure of personal information, steps taken to protect the information and your right to review your personal information. By signing this form, you agree that:

• Grand River Sports Medicine Centre (GRSM) may collect, use and disclose personal information about you as set out in this form and in GRSM’s Privacy Policy;
• You understand how our Privacy Policy applies to you;
• You have had an opportunity to ask any questions you have about our Privacy Policy and they have been answered to your satisfaction;
• You understand there are some rare exceptions to the commitments in our Privacy Policy, as explained in the Policies and Procedures for Personnel Information issued by the Government of Canada.