Please sign within the box.
You consent to the collection and storage of such information as this practice deems necessary for my optimal medical and physiotherapy treatment. You also consent to the release of your medical and physiotherapy details to your family doctor, surgeon or Case Manager.
You (the client) accept responsibility for payment of all your accounts..
Non attendance and Cancellations:
We require a minimum of 24 hours notice if you wish to cancel an appointment to allow us the opportunity to offer the appointment to other clients. Non attendance of appointments and cancellations without 24 hours notice will incur full treatment costs.
Consent to treatment - Physiotherapy:
Due to the nature of physiotherapy you may be required to remove some items of clothing, and some treatment techniques will involve discomfort. At times we will use treatment tools such as the Body Spanner, Superthumb, Ultrasound, Interferential, heat and ice. It is your right at any time to question any aspect of treatment and you may request a technique is terminated at any time.
If you have any concerns regarding the progression of your condition, please discuss this with your Physiotherapist. We are happy to refer you to your GP for an opinion or further investigations at any time.
Consent to treatment - Massage:
Draping will be used appropriately during your massage session – only the area being worked on will be uncovered. Clients aged 16 or under must be accompanied by a parent or legal guardian during the entire session. Informed, written consent must be provided by parent or legal guardian, for any client 16 or under before commencement of treatment.
You have chosen to consult with a massage therapist and hereby give consent for massage therapy to be provided.
It is your right at any time to question any aspect of treatment and you may request a technique is terminated at any time.
You will provide a detailed medical history. You do not expect the therapist to have foreseen any previous or pre-existing condition that you have not mentioned. You understand that massage may provide benefits for certain conditions but results are not guaranteed. These benefits may include relief of muscular tension, relaxation, reduction in the symptoms of stress-related conditions and provision of general wellbeing.
You also understand that massage therapy may produce side effects such as muscle soreness, mild bruising, increased awareness of areas of pain and light-headedness amongst other possible temporary outcomes. You are aware that the therapist does not diagnose illnesses, prescribe medications nor physically manipulate the spine or its immediate articulations.
The therapist understands that you have the right to question procedures used and to receive an explanation of any procedures that the therapist performs. You will tell the therapist about any discomfort you may experience during the therapy session and understand that the therapy will be adjusted accordingly.
Exercise Class Waiver of Liability:
You hereby agree to the following:
1. That you are participating in the Exercise Classes, Hydrotherapy, Programs or Workshops offered by Bounce Physio and its instructors during which you will receive information and instruction about health and fitness. You recognize that fitness programs require physical exertion that may be strenuous and may cause physical injury, and you are fully aware of the risks and hazards involved. You understand that all reasonable efforts will be made to ensure your physical safety. You understand that the equipment can be dangerous if used improperly and you will follow the strict instructions given by your instructor with respect to all of the equipment used.
2. You understand that it is your responsibility to consult with a physician prior to and regarding your participation in the Exercise Classes, Hydrotherapy, Programs or Workshops. You represent and warrant that you are physically fit and you have no medical condition that would prevent your full participation in the Exercise Classes, Hydrotherapy, Programs or Workshops.
3. In consideration of being permitted to participate in Exercise Classes, Hydrotherapy, Programs or Workshops, you agree to assume full responsibility for any risks, injuries or damages, known or unknown, which you (or an unborn child or children you may be carrying) might incur as a result of participating in the program. You are aware of your personal limitations, and are responsible for not exceeding these boundaries.
4. In consideration of being permitted to participate in Exercise Classes, Hydrotherapy, Programs or Workshops, you knowingly, voluntarily and expressly waive any claim you may have against Bounce Physio and its instructors for injury or damages that you may sustain as a result of participating in the program.
5. You, your heirs or legal representatives forever release waive, discharge and covenant not to sue Bounce Physio and its instructors for any injury or death caused by their negligence or other acts.