In-Clinic Consent Form
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 I understand that for the duration of my treatment, my consent may be withdrawn at any time and that I must inform my physiotherapist.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
Physicians at GRSM specialize in sports medicine and are certified with the Canadian Academy of Sport Medicine (CASM) . Our physicians provide expert medical care for both high performance athletes, recreational athletes and active individuals.
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