Consent Form for Virtual Physiotherapy
By joining a phone and/or virtual (telerehab) appointment with InPursuit Physiotherapy:
I agree that I am attending InPursuit Physiotherapy to receive virtual Physiotherapy assessment and treatment.
I understand that a Physiotherapist will conduct an individualized assessment; which may include asking me questions and doing a physical and movement exam of the external muscular, vascular, and nervous systems. I am to report my symptoms, thoughts, and feelings with the assessment as this will guide the Physiotherapist. This can be stopped at any time.
I understand there are some limitations to virtual Physiotherapy assessment or treatment. These include, but are not limited to, not having hands-on assessment and treatment which may impact my care, reliance on technology which may vary in quality and consistency of an internet connection. My Physiotherapist may discuss this with me at the appointment.
I understand that there are different safety risks associated with different types of Physiotherapy appointments, such as the Physiotherapist not being physically present during a virtual appointment. An individualized safety plan will be discussed with my therapist and put in place at the beginning of my virtual appointment.
The Physiotherapist will explain their findings, discuss treatment goals, and explain all aspects of care, and I am to ask questions for clarification purposes when needed.
I understand that I can stop the assessment/treatment at any time, and all aspects of Physiotherapy assessment/care are optional for me.
I understand that all industry-standard privacy precautions are taken with my electronic information, but there may still be a risk to the anonymity of information.
I understand that there is a treatment fee payable at the end of my appointment time. Payment and receipts will be provided electronically.
I understand that it is my responsibility to confirm if my private insurance company will provide coverage for my appointment.
Your Physiotherapist will verify you have read this document at the beginning of your appointment. They will discuss and answer any questions/concerns you may have.
Protecting your Personal Information
The privacy of your personal information is important to our clinic. We are committed to collecting, using, and disclosing personal information responsibly and only to the extent necessary for the goods and services we provide.
Like all medical professionals, we collect, use, and disclose personal information in order to serve our patients. The primary purpose for collecting personal information is to provide treatment.
Like most organizations, we also collect, use, and disclose information for purposes secondary to our primary purposes. The most common examples of our related and secondary purposes are to invoice patients for goods or services that were not paid for at the time, to process credit card payments, or to collect unpaid accounts.
The cost of goods/services provided by the organization to patients is often paid for by third parties (e.g., motor vehicle accident insurance, or private insurance). These third-party payers often have the patient's consent or legislative authority to direct us to collect and disclose certain information to demonstrate patient entitlement to this funding.
Patients or other individuals we deal with may have questions about our goods or services after they have been received. We retain patient information for a mandatory minimum of ten years after the last contact.
We understand the importance of protecting personal information. For that reason, we have taken the following steps:
Paper information is either under supervision or secured in a restricted area.
Electronic hardware is either under supervision or secure in a restricted area at all times.
Paper information is transmitted through sealed, addressed envelopes or boxes by reputable companies.
Electronic information is transmitted either through a direct line, has identifiers removed, or is encrypted.
External consultants and agencies with access to personal information must enter into privacy agreements with me.
You Can Look at Your Information
With only a few exceptions, you have the right to see what personal information we hold about you.
We can help you identify what records we might have about you. We will also try to help you understand any information you do not understand (e.g., short forms, technical language, etc…). We reserve the right to charge a nominal fee for such requests.
Late Cancellation and No Show Policy
If you need to cancel or reschedule your appointment, please call or email us at least 24 hours in advance. Cancellations or missed appointments with less than 24 hours' notice for rehabilitation services will result in a charge of 100% of the appointment fee.
Communicating with Healthcare Professionals
As part of providing comprehensive care, it may be necessary for us to communicate with your primary healthcare provider. This communication allows us to share relevant information about your treatment, progress, and any concerns that may arise. By providing your consent, you help ensure that your healthcare team is fully informed and can work together to support your health and wellness.
Print your name (first and last) below to acknowledge that you have fully read and understand the aforementioned consent statements, and are entering into them voluntarily. *
Check the box below to acknowledge that you fully understand the aforementioned consent statements and are entering into them voluntarily. *
◽️ I give my consent to the aforementioned statements.