Physio Patient Information (Page 2 of 3) in pdf

Athletic Quest International Inc. Elena Ojolick B.Sc.PT

Myofascial Release/Physical Therapy Consent Form

Name:____________________________

Date:_____________________________

I hereby give permission to the physical therapist to do an assessment and/or administer treatment for

the purpose of soft tissue rehabilitation.

I understand that the assessment and treatment for physical therapy at Summit Integrated Health Centre,

Athletic Quest International is NOT COVERED under the Alberta Health Care Insurance Plan. I

understand that I am fully responsible for all assessment and treatment costs upon receipt of service.

THE COST PER ASSESSMENT AND TREATMENT SESSION IS $110.00.

Payments may be made by cash, cheque, debit, Visa, & M/C. Receipts are issued per visit. I understand

that reimbursement for assessment and/or treatment costs by any insurance plan is the sole

responsibility of the client.

I also understand that any release of information, including treatment notes, progress reports and

medical legal reports will NOT be released without my written consent detailing what information is to

be released and to what source it is to be released to. (Physician, Insurance, Therapist)

I do consent to the release/sharing of information (including medical reports, chart notes and history)

between therapists within Summit Integrated Health Centre, Athletic Quest International for the

purpose of comprehensive assessments and treatment.

I allow the release of information to the following outside sources only as listed below:

________________________________________________

Initial__________

I understand that twenty-four (24) hours notice of cancellation of an appointment is required. We

have an answering machine on which a message can be left when we are not in the office. A time and

date is stamped when the message is left. Any cancellations that are NOT made 24 hours in advance,

the full amount of the appointment will be charged (unless there is mediating circumstances). The cost

of the cancelled appointment will be the responsibility of the client.

Signature:_________________________________________

Therapist signature:_________________________________

Physio Patient Information Page 2