New Patient Form - Osteopathy Page 2

 

 

 

S P O R T S

I N J U R Y

C E N T R E

 

TERMS   A ND   C ONDITIONS   A ND   I NFORMED   C ONSENT   T O   O STEOPATHIC   T REATMENT  

 

When   p erformed   b y   a   q ualified   o steopath,   o steopathic   m anipulation   o f   t he   s pine   a nd   o ther   j oints,   m uscles   a nd  

other   p arts   o f   t he   m usculoskeletal   s ystem   i s   a n   e ffective   a nd   s afe   m ethod   o f   t reatment   f or   m any   c onditions.   T here  

are,   h owever,   r isks   a ssociated   w ith   a ny   t reatment   a nd   w e   a re   r equired   t o   i nform   y ou   o f   t hese,   e ven   t hough   t here  

has   n ever   b een   a   c ase   i n   t his   c linic.  

Please   r ead   t he   f ollowing   c arefully   a nd   d iscuss   a ny   q uestions   y ou   m ay   h ave   w ith   y our   t reating   p ractitioner.   I f   y ou  

agree   w ith   t he   f ollowing,   p lease   f ill   o ut   t he   n ame   o f   y our   o steopath   a nd   s ign   a nd   r eturn   t his   f orm   t o   y our   t reating  

osteopath.  

I   r equest   a nd   c onsent   t o   t he   p erformance   o f   o steopathic   m anipulation   a nd   o ther   o steopathic   p rocedures.  

I   c onfirm   t hat   I   h ave   h ad   t he   o pportunity   t o   d iscuss   w ith   t he   o steopath   n amed   b elow   t he   n ature   a nd   p urpose   o f  

osteopathic   m anipulation   a nd   o ther   o steopathic   p rocedures.   I   u nderstand   t hat   r esults   a re   n ot   g uaranteed.  

I   u nderstand,   a nd   a cknowledge   t hat   I   h ave   b een   i nformed   t hat,   i n   t he   p ractice   o f   o steopathy,   a s   i n   t he   p ractice   o f  

medicine,   t here   a re   s ome   v ery   s light   r isks   t o   t reatment   i ncluding,   b ut   n ot   l imited   t o,   m uscle   a nd   j oint   s oreness,   m uscle  

strains,   j oint   s trains,   f ractures,   d isc   i njuries   a nd   s trokes.   I   d o   n ot   e xpect   t he   o steopath   n amed   b elow   t o   b e   a ble   t o  

anticipate   a nd   e xplain   a ll   o f   t he   r isks   a nd   p ossible   c omplications   t o   m e.   I   w ish   t o   r ely   o n   t he   o steopath   t reating   m e   t o  

exercise   h is   o r   h er   j udgment   d uring   t he   c ourse   o f   m y   t reatment   i n   s uch   a   m anner   a nd   t o   t he   e xtent   t hat   h e   o r   s he   f eels  

at   t he   t ime,   b ased   o n   t he   f acts   t hen   k nown,   i s   i n   m y   b est   i nterests.  

I   h ave   r ead   t he   a bove,   a nd   c onfirm   t hat   I   h ave   a lso   h ad   t he   o pportunity   t o   a sk   q uestions   a bout   i ts   c ontent.   I   i ntend   t his  

consent   f orm   t o   c over   t he   e ntire   c ourse   o f   t reatment   f or   m y   p resent   c ondition,   a nd   f or   a ny   o ther   f uture   c ondition(s)  

for   w hich   I   s eek   t reatment.     I   u nderstand   t hat   I   c an   w ithdraw   m y   c onsent   a t   a ny   t ime   i n   w riting.  

Future   a ppointments   a t   t his   c linic   m ay   b e   r equired   t o   b e   b lock   b ooked   t o   e nsure   o ptimal   o utcome   f or   y our   c ondition,  

illness   o r   i njury.  

  B y   t icking   t his   b ox,   I   c onsent   t o   r eceiving   e mails   f rom   t ime   t o   t ime   r egarding   t he   s ervices   o f   M elbourne   O steopathy  

Sports   I njury   C entre,   u ntil   f urther   n otice.  

This   c linic   h as   a   2 4   h our   c ancellation   p olicy   t hat   a pplies   t o   a ll   a ppointments.   F ailure   t o   p rovide   2 4   h ours   n otice   w hen  

changing   o r   c ancelling   a ppointment   t imes   a nd   m issed   a ppointments   w ill   r esult   i n   b eing   c harged   t he   f ull   a ppointment  

fee.     I t   i s   e xpected   t hat   y ou   w ill   p ay   f or   e ach   a ppointment   a t   t he   e nd   o f   y our   s ession.  

If   y ou   a re   h appy   w ith   y our   c onsult   w e   w ould   a ppreciate   i t   i f   y ou   c ould   r efer   f riends   a nd   f amily   t o   o ur   c entre.  

At   t he   e nd   o f   y our   f irst   t reatment   y ou   w ill   b e   r equired   t o   f ill   i n   t he   p atient   f eedback   f orm.  

 

Osteopath's   N ame   _ _____________________________  

 

Patient’s   N ame   _ ________________________________       P atient's   S ignature   _ _________________________________  

 

Date:   _ ______________________