Sample consent forms

Below are two sample consent forms:

Informed Consent for Assessments
Informed Consent for Pelvic Health Physiotherapy

You can use these consent forms by copying the text and pasting it into either the consent form feature or questionnaire feature on Embodia. Proof read them and update the relevant information such as the clinic name, profession, cancellation policy, etc.

Important: Embodia is not responsible or liable for the content of the sample consent forms. If you choose to use them, please review them carefully and make any adjustment necessary. If you are unclear about the content, please consult your lawyer.

By joining a phone and/or virtual (telerehab) and/or in-clinic and/or in-home appointment with CLINIC:

I agree that I am attending CLINIC to receive PROFESSION assessment/treatment
I understand that CLINIC will conduct an individualized assessment which may include asking me questions and doing a physical and movement exam of the external muscular, vascular and nervous system. I am to report my symptoms, thoughts and feelings with the assessment as this will guide the healthcare practitioner. This can be stopped at any time.
I understand there are some limitations to PROFESSION assessment or treatment virtually such as not having a hands-on assessment which may impact my care. My healthcare practitioner will discuss this with me at the appointment.
The healthcare practitioner will explain their findings, discuss treatment goals and explain all aspects of care, and I am to ask questions for clarification purposes when needed.
I understand I can stop the virtual assessment/treatment at any time and all aspects of PROFESSION assessment/care are optional for me.
I understand that all industry-standard privacy precautions are taken with my electronic information, but there may still be a risk to the anonymity of information.
I understand that there are different safety risks associated with different types of PROFESSION appointments, such as the v not being physically present during a virtual appointment. An individualized safety plan will be discussed with my therapist and put in place at the beginning of my virtual appointment.
I understand that there is a treatment fee payable at the end of my appointment time. Payment and receipts will be provided electronically.
I understand that it is my responsibility to confirm if my company will still provide coverage for my appointment.

Your healthcare practitioner will verify you have read this document at the beginning of your appointment. They will discuss and answer any questions/concerns you may have.

PROTECTING PERSONAL INFORMATION

The privacy of your personal information is important to our clinic. We are committed to collecting, using and disclosing personal information responsibly and only to the extent necessary for the goods and services we provide.

Like all medical professionals, we collect, use and disclose personal information in order to serve our patients. The primary purpose for collecting personal information is to provide treatment.

Like most organizations, we also collect, use and disclose information for purposes secondary to our primary purposes. The most common examples of our related and secondary purposes is to invoice patients for goods or services that were not paid for at the time, to process credit card payments or to collect unpaid accounts.

The cost of goods/services provided by the organization to patients is often paid for by third parties (e.g., motor vehicle accident insurance, private insurance). These third party payers often have the patient consent or legislative authority to direct us to collect and disclose certain information in order to demonstrate patient entitlement to this funding.

Patients or other individuals we deal with may have questions about our goods or services after they have been received. We retain patient information for a mandatory minimum of ten years after the last contact.

We understand the importance of protecting personal information. For that reason, we have taken the following steps:

Paper information is either under supervision or secured in a restricted area.
Electronic hardware is either under supervision or secure in a restricted area at all times.
Paper information is transmitted through sealed, addressed envelopes or boxes by reputable companies.
Electronic information is transmitted either through a direct line or has identifiers removed or is encrypted.
External consultants and agencies with access to personal information must enter into privacy agreements with me.

YOU CAN LOOK AT YOUR INFORMATION

With only a few exceptions, you have the right to see what personal information we hold about you.

We can help you identify what records we might have about you. We will also try to help you understand any information you do not understand (e.g., short forms, technical language, etc.). We reserve the right to charge a nominal fee for such requests.

LATE CANCELLATION OR NO SHOW POLICY

If you need to cancel or reschedule your appointment, please call or email us at least 24 hours in advance. Cancellations or missed appointments with less than 24 hours' notice for rehabilitation services will result in a charge of 100% of the appointment fee.

Pelvic health physiotherapy, also referred to as pelvic floor physiotherapy, consists of the assessment and treatment of a variety of conditions in which the muscles of the pelvic floor play an important role. These conditions are wide-ranging and can occur across all ages and genders. A few of the most common conditions that can benefit from pelvic floor physiotherapy include:

low-back, pelvic, or hip pain
urinary or fecal incontinence
chronic constipation or difficulty voiding
problems related to the menstrual cycle (including endometriosis)
pelvic organ prolapse
dyspareunia (pain with intercourse), or other difficulties with sexual function
painful scars in the pelvic region, such as those associated with surgery or childbirth
diastasis recti abdominis

In order to better assess the structures of the pelvic floor, pelvic health physiotherapists have additional training enabling them to visualize and palpate the structures of the pelvic floor through internal assessments and treatments. These internal assessments and treatments can be performed vaginally and/or rectally. Your pelvic health physiotherapist may recommend internal work, but it is always your choice whether or not you would like to be assessed and treated in this manner. Here are a few benefits and risks to consider:

Benefits of internal assessment and treatment:

more accurate assessment of the state of the pelvic floor tissues, including identifying tight/overactive muscles as well as muscle strength/endurance/coordination/timing/ability to release;
more accurate targeting of treatment to specific tissues.

Risks of internal assessment and treatment:

pain or discomfort (during or after the assessment/treatment)
spotting or bleeding (during or after the assessment/treatment)
skin reaction or irritation in response to the gel or gloves used
emotional discomfort or anxiety
nausea or lightheadedness
miscarriage during pregnancy

Given the above information, and in consultation with my physiotherapist, I would like to proceed with an internal assessment, recognizing that I can withdraw my consent at any time. If I feel physical or emotional discomfort at any point during the procedure, I will inform my physiotherapist so that appropriate modifications can be made, including discontinuing the procedure.

***If you are pregnant, have infections of any kind, have vaginal dryness, are less than 6 weeks postpartum or post-surgery, have severe pelvic pain, are using an IUD, have sensitivity to lubricants or latex, or have recently undergone radiation, please inform your physiotherapist prior to this procedure.