GENERAL PHYSIOTHERAPY INFORMED CONSENT FORM

(Manual Physical Therapy and Routine Physiotherapy Services)

PURPOSE OF THIS CONSENT

This form is intended to document informed consent for general physiotherapy assessment and treatment provided by the physiotherapist identified above. It applies to routine physiotherapy services and manual physical therapy interventions. It does not apply to specialized procedures requiring separate informed consent, including but not limited to dry needling/IMS, shockwave therapy, pelvic floor internal assessment, or other specialized interventions.

Please read this form carefully and ask any questions you may have before signing.

DESCRIPTION OF PHYSIOTHERAPY SERVICES

Physiotherapy is a health care profession that assesses, diagnoses, treats, and helps prevent physical impairments, movement dysfunction, pain, and disability. General physiotherapy assessment and treatment may include, but is not limited to:

• Review of health history and relevant medical information
• Physical examination and functional assessment
• Observation of posture, movement, strength, flexibility, balance, coordination, and functional abilities
• Palpation and hands-on examination of muscles, joints, tendons, ligaments, and other tissues
• Manual therapy techniques
• Joint mobilization
• Soft tissue techniques
• Stretching and flexibility interventions
• Therapeutic exercise prescription and progression
• Education regarding injury, condition, recovery, activity modification, and self-management
• Home exercise programs
• Functional retraining and rehabilitation activities
• Use of physiotherapy equipment commonly associated with routine physiotherapy care

Your physiotherapist will explain the assessment findings, treatment recommendations, and any significant risks or alternatives relevant to your individual circumstances.

EXPECTED BENEFITS

Potential benefits of physiotherapy may include:

• Reduction of pain and discomfort
• Improved mobility, flexibility, and function
• Improved strength, endurance, and physical performance
• Enhanced recovery from injury or surgery
• Improved ability to perform work, sport, recreational, and daily activities
• Prevention of further injury or impairment
• Increased understanding of your condition and strategies for self-management

Although physiotherapy is often beneficial, no specific outcome or guarantee of improvement can be promised.

POTENTIAL RISKS AND SIDE EFFECTS

As with any health care service, physiotherapy involves some risks. While serious complications are uncommon, possible risks and side effects may include:

• Temporary soreness, stiffness, tenderness, or discomfort
• Temporary increase in symptoms
• Muscle fatigue
• Bruising or skin irritation
• Temporary dizziness or lightheadedness
• Aggravation of an existing condition
• Falls or loss of balance during assessment or exercise activities
• Rare strains, sprains, or other injuries associated with physical activity or manual treatment

Your physiotherapist will take reasonable precautions to reduce risks and will discuss any material risks that may be particularly relevant to your condition or proposed treatment plan.

ALTERNATIVES

You have the right to:

• Accept the recommended physiotherapy services
• Decline any recommended assessment or treatment component
• Request modification of a treatment approach
• Seek a second opinion
• Choose alternative treatment options
• Refuse treatment altogether

Your physiotherapist will discuss reasonable alternatives and the potential consequences of declining recommended care where appropriate.

VOLUNTARY CONSENT

I understand that:

• My participation in physiotherapy is voluntary.
• I am free to ask questions at any time.
• My questions will be answered to the best of the physiotherapist’s ability.
• I may request additional information before making decisions regarding my care.
• No pressure, coercion, or guarantee of outcome has been used to obtain my consent.

ONGOING CONSENT AND RIGHT TO WITHDRAW

I understand that:

• Consent is an ongoing process and not a one-time event.
• I may withdraw or modify my consent at any time and for any reason.
• I may ask that any assessment or treatment be stopped immediately.
• I may refuse any specific assessment or treatment technique without affecting my right to receive other appropriate physiotherapy services.
• My physiotherapist will seek my ongoing agreement to proceed throughout assessment and treatment sessions.
• Withdrawal of consent will be respected.

I understand that choosing not to proceed with recommended treatment may affect my recovery or treatment outcomes, and these implications may be discussed with me.

PROVIDER-SPECIFIC CONSENT

I understand that this consent applies specifically to the physiotherapist identified on this form.

I understand that:

• I have the right to know who is providing my care.
• If another physiotherapist, physiotherapy student, physiotherapist support worker, or other authorized individual will participate in my care, I may be informed and may accept or decline their involvement where applicable.
• I may request clarification regarding who is involved in my treatment at any time.

PRIVACY AND CONFIDENTIALITY

I understand that my personal and health information will be collected, used, stored, and disclosed in accordance with applicable privacy legislation, professional standards, and clinic policies for the purposes of providing physiotherapy services and administering my care.

I understand that my information may be shared with other health care providers, insurers, funding agencies, legal representatives, or other authorized parties only where permitted or required by law, or with my authorization. I understand that and consent to being contacted by the clinic for appointment scheduling, reminders, treatment-related communication, and administrative purposes via phone, voicemail, text message, and email.

PATIENT ACKNOWLEDGEMENT

By signing below, I acknowledge and confirm that:

• I have received information regarding the proposed physiotherapy assessment and treatment.
• The nature and purpose of physiotherapy services have been explained to me.
• Potential benefits, risks, and alternatives have been discussed with me.
• I have had the opportunity to ask questions.
• My questions have been answered to my satisfaction.
• I understand that no guarantee or assurance regarding treatment outcomes has been made.
• I understand that I may refuse or withdraw consent at any time.
• I voluntarily consent to receive general physiotherapy services from the physiotherapist identified on this form.