Physiotherapy Consent Form

Your physiotherapist will outline a recommended action plan as the best plan for your injury. You will achieve the maximum and best outcome when you keep your recommended action plan to this schedule. We have a long waiting list of patients trying to get appointments and poorly timed cancellations prevent us from offering these appointments to those who are needing our care.

Full Name

Contact Number

Email Address

Consent to Terms & Conditions for Physiotherapy

•I understand that All Massage Services provided by a physiotherapist are to be billed as physiotherapy for private health insurance claims. •I understand that payment is required at the conclusion of each consultation. •I understand that I will be personally responsible for all fees on my account. •I understand that I am consenting to receive email marketing. •I understand and accept the precautions and contraindications of each treatment on the bottom of this page. •I have advised my physiotherapist of any medical conditions or contraindications that may impact my treatment. •All missed appointments and cancellations made within 8 hrs of a scheduled appointment will result in a cancellation fee of $65. •Your physiotherapist will outline a recommended action plan as the best plan for your injury. You will achieve the maximum and best outcome when you keep your recommended action plan to this schedule. •I understand that if I arrive at the practice late to an appointment, I will only receive treatment up until the end of my scheduled appointment time unless the physiotherapist determines there is insufficient time to conduct an adequate assessment.

Precautions and Contraindications

Massage Therapy: Precautions: Warfarin – anticoagulant medications, Varicose veins, Cancer, Open sores, Active infection, Recent airplane travel (<2 weeks)

Contraindications for 1st Trimester of Pregnancy: History of bleeding •Abdominal pain •Nausea or hyperemesis gravidarum •Fever and malaise •History of previous miscarriage •Poor outcome in previous pregnancy •Previous late term loss (past 20 weeks gestation) •Placental abruption in previous pregnancy •Pre‐existing high-risk condition prior to pregnancy, including but not limited to, diabetes, kidney, hypertension and cardiac disease

Acupuncture / Dry Needling: Precautions: Acupuncture should be used with caution on pregnant patients

Exercise & Pilates: Precautions: •High blood pressure •Beta blocker medications, CNS, CVS medications •Any Skeletal or Neuromuscular disorders, back problems etc •Previous Heart Condition •Advanced Pregnancy

Contraindications: •A history Recent Heart Attack, also called Myocardial Infarction •Any heart related disease including but not limited to Aortic Stenosis, Unstable Angina, Pericarditis or any thromboembolic disease •Severe Infections and Fever •Severe Illness of any kind

Bracing / Taping / Casting: Contraindications: •Allergy to taping materials •Open wounds •Active infection or irritation of area of skin to be taped •History of hyper sensitive skin or pre-existing skin conditions e.g.; psoriasis, eczema, dermatitis •Circulation compromised in area •Sensation compromised in area •No one available at home to remove tape, plaster, brace if it causes irritation or discomfort