INFORMED CONSENT TO PHYSIOTHERAPY TREATMENT
I hereby request and consent to the performance of physiotherapy treatments and other physiotherapy
procedures and techniques, including various modes of physical modalities, manual techniques and exercise on
me by the physiotherapist. Physiotherapy assistants/kinesiologist will be part of providing treatment and will
work under physiotherapist supervision named below or any provider covering for the treating physiotherapist
working in this clinic authorized by the physiotherapist.
I have had the opportunity to discuss with the physiotherapist named below the nature and purpose of
physiotherapy treatment and other procedures. I understand that results are not guaranteed and only the treating
physiotherapist will be responsible for any issues related or arising from treatment not the clinic, as all health
care practices, there are some slight risks of injury with treatment including, but not limited to, soft tissue
sprains/ strains, pain, heart attacks, stroke, etc. and agree to keep the therapist informed of any changes in my
condition (sometimes patients get bruising from soft tissue that’s normal). Also, I had the opportunity to discuss
the payment plan with the office administration regarding my private insurance, WSIB and MVA before IA.
FEE STRUCTURE FOR WSIB AND MVA:
ALL WSIB AND MVA PAYMENTS WILL BE CHARGED AS PER THE STANDARD FEE GUIDE.FOR MVA WILL GO THROUGH YOUR EXTENDED HEALTH INSURANCE FIRST.PER SESSION COST IS $99.75 AND INITIAL ASSESSMENT IS $215 FOR MVA.
PRIVATE INSURANCE FEE STRUCTURE:
- INITIAL ASSESMENT FOR ONE PART: $ 115
- FOLLOWS UP SESSIONS: $75
- INITIAL ASSESMENT FOR MULTI PARTS: $140
- FOLLOWS UP SESSIONS: $100
- INITIAL FOR TMJ: $130
- FOLLOWS UP: $100
- INITIAL FOR VESTIBULAR: $130
- FOLLOW UP: $100
- LASER THERAPY: $100 PER SESSION
- SHOCKWAVE: $120 PER SESSION
- ACCUPUNTURE $100 TRACTION: $100 PER SESSION
- INITIAL ASSESSMENT CONCUSSION: $130
- FOLLOWS UP SESSIONS: $100
CONSENT TO PAYMENT
I understand that I am responsible for payment of any fee for each treatment unless this is paid for by my
motor vehicle insurer or the Work Place Safety and Insurance Board.
I understand that I am responsible for keeping scheduled appointments and that I will be charged a full
treatment charge for appointments missed including WSIB/MVA without prior cancellation by phone or
in person. All overdue and outstanding payments will be charged with an additional 5% interest after 30
days and any pending accounts after 30 days will be transferred to our accounts department.