Specialized Physiotherapy Consent Form SPECIALIZED PHYSIOTHERAPY PROCEDURES CONSENTPatient Name*I am a Parent or Legal Guardian Consenting on Behalf of a MinorParent/Legal Guardian Name*Parent/Legal Guardian Relationship to the Minor*Patient Date of Birth*Current Date*Physiotherapist*Manpreet Kaur PTPlease select the procedure(s) for which you are providing consent today:* Dry Needling / IMSShockwave TherapyPelvic Floor Internal Assessment and/or TreatmentOther Specialized Procedure(s) (Please Specify)Please specify other specialized procedure(s):*SECTION A – DRY NEEDLING / IMS CONSENT Dry Needling / Intramuscular Stimulation (IMS) involves the insertion of sterile single-use needles into muscles and other soft tissues for therapeutic purposes. Potential Benefits: • Pain reduction • Improved mobility and function • Reduced muscle tension • Improved movement patterns Potential Risks and Side Effects: • Temporary soreness • Minor bleeding • Bruising • Fatigue • Dizziness or fainting • Infection (rare) • Nerve irritation (rare) • Pneumothorax/lung injury (extremely rare) I understand the nature, purpose, benefits, alternatives, and potential risks of Dry Needling / IMS. I have had the opportunity to ask questions and all questions have been answered to my satisfaction. I consent to Dry Needling / IMS treatment.Patient Initials:*Parent/Legal Guardian Initials:*SECTION B – SHOCKWAVE THERAPY CONSENT Shockwave Therapy uses acoustic pressure waves to assist in the treatment of certain musculoskeletal conditions. Potential Benefits: • Pain reduction • Improved healing response • Improved mobility and function • Enhanced recovery Potential Risks and Side Effects: • Temporary discomfort during treatment • Redness • Swelling • Bruising • Temporary increase in symptoms • Skin irritation I understand the nature, purpose, benefits, alternatives, and potential risks of Shockwave Therapy. I understand that outcomes may vary and multiple treatment sessions may be recommended. I consent to Shockwave Therapy treatment.Patient Initials:*Parent/Legal Guardian Initials:*SECTION C – PELVIC FLOOR INTERNAL ASSESSMENT AND/OR TREATMENT CONSENT I understand that my assessment and/or treatment may involve an internal vaginal and/or rectal examination when clinically indicated. I understand that: • The purpose of the internal examination has been explained to me. • I may refuse or withdraw consent at any time. • I may request clarification at any point. • My privacy and dignity will be respected. • I may request the presence of a support person or chaperone where available. Potential Risks: • Temporary discomfort • Mild soreness • Emotional discomfort • Minor irritation or spotting I understand the nature, purpose, benefits, alternatives, and potential risks of this assessment and/or treatment. I consent to Pelvic Floor Internal Assessment and/or Treatment.Patient Initials:*Parent/Legal Guardian Initials:*SECTION D – OTHER SPECIALIZED PROCEDURE CONSENT Procedure Name:*Description of Procedure:*Potential Benefits Discussed:*Potential Risks Discussed:*I confirm that the nature, purpose, benefits, alternatives, and potential risks of the procedure listed above have been explained to me.I consent to the procedure described above.Patient Initials:*Parent/Legal Guardian Initials:*GENERAL ACKNOWLEDGEMENT I acknowledge and understand that: • I have received information regarding the procedure(s) selected above. • I have had the opportunity to ask questions. • My questions have been answered to my satisfaction. • No guarantee or assurance regarding treatment outcomes has been made. • I may withdraw my consent at any time. • I understand that treatment recommendations are based on clinical judgment and my individual circumstances. By signing below, I voluntarily consent to the selected procedure(s).Signature Image Patient/Legal Guardian Signature (required) Clear Signature Save Signature Date*SendThis field should be left blank
