Consent Form (Physiotherapy, Massage and Acupuncture)

Physio-Flex

Physio-Flex provides Physiotherapy, Sports and Therapeutic Massage and Acupuncture patient care services that help in the management of a wide variety of conditions.

 

The purpose of the services we provide is to examine, evaluate, diagnose and establish an adequate intervention plan and prognosis in the treatment of your presenting problem. In the process of treatment we will use a variety of treatment and rehabilitation techniques to aim to reduce length of functional restriction and maximise potential recovery.

 

All procedures will be thoroughly explained to you before application. Response to intervention varies from person to person, and therefore, there is a possibility that the treatment may result in short term aggravation of existing symptoms and may cause pain, bruising or injury.  Physioflex does not guarantee that the treatment provided will help to resolve the condition you are seeking treatment for but will use best evidence and clinical judgement in the application of your treatment.

 

It is your right to discuss the potential risks and benefits involved in your treatment and decline any part of your treatment at any time before or during treatment, should you feel any discomfort or pain or have other unresolved concerns.

 

Chaperone: If you are under 16 or classed as a vulnerable adult you must have an appropriate adult or carer in attendance.

 

Medical Conditions: This consent implies that you agree to disclose any and all relevant medical information requested by the treating clinician e.g. X-ray or MRI results, the presence of conditions such as Asthma, Diabetes, Hearth conditions, High blood pressure, Metal implants, pregnancy and others.  

 

Consent:

I have read this consent form and understand the risks involved in treatments provided by Physioflex and agree to fully cooperate, participate in all treatment procedures, and comply with the established plan of care.

 

I authorise the release of my medical information to appropriate third parties provided it is either medically to my benefit, (i.e. GP, Medical Practitioner, Insurance Companies) or as dictated by law.

 

I consent to the assessment and treatment recommended and performed by the practitioner at Physioflex in accordance with the governing body’s professional guidelines. I understand that before any treatment is carried out, a full explanation of the purpose and any risks of that treatment will be given, and based on that information I am entirely within my right to refuse treatment and that I should inform the clinician of my wishes at the time.

 

I understand and accept it is my responsibility to ensure prompt settlement of any fees and not that of a medical insurance company or third part. Therefore, if, for whatever reason, my medical insurance company or third party do not pay my fees within 30 days I will be asked to pay Physioflex directly.

 NOTES:

Cancellation Policy: Clients who book at Physioflex are required to give 24 hours advanced notice of their inability to attend or change their appointment, otherwise they will be charged £12:50 for the appointment if they fail to do so. This policy is deemed necessary to avoid denying appointments to patients who may be on the waiting list.

Data protection: All the information collected in the course of your assessment and treatment at Physioflex will remain strictly confidential under the terms of the Data Protection Act 2018 and the General Data Protection Regulation (EU) 2016/679, (GDPR)

 

We provide our services to individuals of all ages regardless of gender, colour, ethnicity, creed, nationality or disability.

 

Consent Signature Form

We can’t guarantee full recovery for all problems as this is just not possible for chronic conditions. Our job, in that situation, is to help you to understand and manage your condition to maximise your function, recovery and pain management.
What we do care about is the way we treat you.
We care about you and the service we provide you.
If you are NOT happy with our service or approach then please let us know. We would love the opportunity to immediately rectify it. We all make mistakes but we believe in making as few as possible, and when we do, we look to make things right.

At any point if you are still unhappy with our service we will immediately refund your treatment fee.

Caroline Bennett
On Behalf of PhysioFlex (West Lothian) Ltd