The Ontario Government prefers the patient to give consent to treatment in writing. By signing this Consent Form you acknowledge that you consent to treatment and have had your questions about treatment answered to your satisfaction.
Osteopathy, Physiotherapy, Massage, to name the few treatments we provide may include manual therapies where the health practitioner places his or her hands on your body such as your anterior chest wall, pelvis floor and pubic bones. We may ask you to remove some of your clothing and will drape you appropriately to facilitate treatment. You need to be aware that many treatment techniques may involve some contact between your body and the health practitioner’s body. For certain osteopathic internal treatments, we may have to work in your mouth. In this case, a disposable vinyl glove will be worn.
We, as a team, are committed to providing an excellent quality of treatment and hospitality to our patients. If you do not feel comfortable with a given technique, please tell your practitioner immediately. The technique will be discontinued or modified so it is comfortable for you.
On January 1, 2004, the Personal Information Protection and Electronic Documents Act (the Act) came into effect with a mandate to balance the privacy rights of the individual and the needs of commercial organizations to collect information for business purposes.
CO is responsible for maintaining and protecting all information collected by the clinic.
CO limits the collection of personal information to only that which is necessary for the provision of excellent health care. This information is accurately maintained in its most current form in order to fulfill the purposes for which it was collected.
A decision to receive care at CO implies consent for the sharing of information internally, for purposes related to your health care only. Written consent is required from you in order to share your health care information externally. You may withdraw this consent in writing at any time.
Patient information is kept in a secure manner for a period of 10 years. This information will only be utilized for the purposes for which it was collected or if required by law.
Appropriate security measures are utilized to secure the privacy of all information collected in the delivery of your health care services.
You are entitled to view the information collected by CO regarding your care. You may obtain a copy of your records. There is a fee for this service.
By signing this form, I hereby give consent to therpist for treatment and also to the collection, use, maintenance and disclosure of my personal information as indicated above, unless and until I advise otherwise in writing.
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