Consent Form

Indemnity Consent
Suitable for: Physiotherapy consultations, Hydrotherapy, Massage & Telehealth

You may choose to consent or refuse any form of treatment for any reason including religious or personal reasons. Once you have given consent, you may withdraw your consent at any time, even if you have previously signed this consent form.

Disclaimer – Risks will differ between various services. The risks will be explained during your consultation or specific screening for a specialised service

Physical Contact
During the massage/treatment it will be necessary for your physiotherapist/ massage therapist to make physical contact with you. The therapist will ask your permission before making physical contact with you in any way. Physical contact requires your consent however, you may withdraw consent at any time at which point, all physical contact will cease immediately. Please inform your therapist if you feel uncomfortable for any reason at any time.

Children and minors
If under 18, consent from a custodial parent/guardian is required to treat a minor. The parent/guardian is recommended to be
present during the consultation/massage.

Substituted Consent
Where a person is incapable of understanding the risks and benefits of treatment, consent may be provided by another person legally authorized to provide such consent. Evidence of legal authorization is required in such circumstances.

Risk related to treatment
As with all forms of treatment, there are risks and benefits. Below are the foreseeable risks you need to be aware of prior to the commencement of the treatment. This is to ensure that you fully understand any potential risks involved. Risks that you could experience but are not likely to occur are:

  • Post treatment soreness (muscle pain and fatigue): It is normal to experience delayed muscle soreness directly
    correlated to the area in which you had the treatment provided for possibly up to 24-48 hours post treatment.
  • Slight dehydration: Due to the redirection in blood flow/fluid from the massage, so keep up your water intake and its
    encouraged to drink water after the massage.
  • Bruising/redness.
  • Headache/migraine
  • Nausea
  • Fatigue/sleepiness.
  • Inflammation, redness and heat & could even aggravate an old injury.
  • Adverse reaction from strapping tape can include but are not limited to the following: burning, stinging, soreness,
    itchiness and redness. If you experience these symptoms or other adverse reactions please remove the tape
    immediately.
  • Slips / trips / falls
  • Heat exhaustion
Medical History
Covid Safe Practice
Client Details
PLEASE COMPLETE THE BELOW IF THE PATIENT IS UNDER THE AGE OF 18.
CONSENT TO TREAT AND CONSENT TO COLLECT AND DISCLOSE INFORMATION:
In accordance with the Federal Government's Personal Information Protection and Electronic Documents Act (PIPEDA) effective January 1, 2004, Sarah’s Physio To Go needs your informed consent to provide assessment and treatment services to you and to collect and use your personal information. We want you to understand the services we provide, and what we may do with your personal information.
1. Consent to treatment
2. Consent to collect and disclose information
Additional Information