CONSENT FOR TREATMENT AND CANCELLATION FEE:
In signing this form I acknowledge that it is my responsibility to inform Move Clinic:
- If I am unable to attend the scheduled appointment time for any reason. I acknowledge that the FULL APPOINTMENT FEE will be charged if I fail to give 24 hours prior notice to cancel an appointment or fail to attend.
- I acknowledge that it is my responsibility to arrive on time for my scheduled appointments, as sessions will finish at the original scheduled time regardless of late arrival. I recognise that arriving 15 minutes early and commencing my warm-up is strongly encouraged.
- I acknowledge that all appointment fees and group sessions are due before the end of the session.
Risks related to treatment:
I appreciate that with any physical exercise/manual therapy there are risks and benefits. Your therapist will discuss any foreseeable risks with you prior to prescribing treatment. By signing this form you are acknowledging these risks and will take care to heed the advice of your therapist.
Questions of a personal nature:
I agree to give details of all related physical issues, including past injuries and any other information that may be relevant to discerning the most appropriate treatment. I accept responsibility to raise any questions I have and inform the therapist if I feel uncomfortable with any procedure or recommendation. I assume responsibility for any consequences of providing false or incomplete information regarding injury/disease.
Clinical Physical Contact:
During your sessions, assessment and ongoing treatment, it may be necessary for your therapist to make physical contact. By signing this form, you consent to Clinical Physical Contact. You may withdraw consent at any time and physical contact will cease immediately.
Children and Minors:
Consent from a custodial parent is required prior to treatment. This applies to anyone under the age of 18.
By signing this form, you are agreeing that your practitioner may discuss your case with another practitioner, trainer or allied health professional for case conferencing or referral purposes. This ensures relevant information is passed between practitioners involved in your care and ensures you receive the highest standard of treatment.
You need to let us know:
The risk related to some exercise disciplines can increase if your therapist is unaware of certain facts, please inform your therapist if you have:
- A pacemaker or cardiac condition
- Suffered from blood clots, thrombosis or stroke
- Suffer from diabetes
- Are currently taking medications
- Have an injury, or history of injury, that may affect the prescription of exercise.