Virtual Physiotherapy Information
and Consent Form

Welcome to Grand River Sports Medicine Centre Inc. We want you to understand and consent to the virtual services we provide to you, the costs involved and what we do with personal information we obtain about you. 

The benefits of virtual physiotherapy involve the convenience of being assessed and treated from home without the need to travel and to allow you to adhere to the current social distancing recommendations.

Consent for Assessment & Treatment

A registered Physiotherapist will complete your virtual assessment. The physiotherapy assessment will involve a detailed history-taking and subjective examination. The objective examination has been modified for the tele-rehab platform and will include visual assessment of movement deficiencies (including joint range of motion), functional testing, and exercise-based analysis. The results of your subjective and objective examination will be analyzed to develop a treatment plan that is specific to your condition. The virtual appointment will also provide education regarding your condition, objective results and treatment plan. Follow up communication via email and the tele-rehab platform will provide you with your comprehensive exercise plan as well as any pertinent injury management strategies that your physiotherapist has discussed with you.

It is important to understand the risks and disadvantages of virtual physiotherapy. Many physiotherapy issues and health concerns can be addressed with virtual care alone, but virtual care is not a substitute for in-person communication or physical examination. In some cases, your physiotherapist may ask you to visit a hospital or other health care facility if necessary, for a physical examination. As a result, we encourage you to have someone present in your home in case of emergency.
We do our best to ensure the information you provide during your virtual care visits is private and secure, but no video or audio tools are completely secure. There is an increased security risk that your health information may be intercepted or disclosed to third parties when using video or audio communications tools. To help us keep your information safe and secure, you can:

  • Understand that this method of communication is not secure in the same way as a private appointment in an exam room or clinic
  • Use a private computer/device (i.e., not an employer’s or third party’s computer/device) and a secure internet connection. For example, using a personal computer or tablet is more secure than at a library, and your access to the Internet on your home network will generally be more secure than an open guest Wi-Fi connection

It is also important to understand that virtual physiotherapy involves risks resulting from misunderstandings due to lack of visual cues and that there is the potential for connection failure. Please discuss alternate forms of communication (i.e., email and phone contact) with your physiotherapist in the event that your communication is disrupted.

To ensure the benefits and potential complications of each chosen treatment are understood, it is the policy of GRSM that the treatment be explained to you by your physiotherapist before initiation, 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 a virtual 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.

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.

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