{"id":7899,"date":"2025-11-19T16:01:03","date_gmt":"2025-11-19T16:01:03","guid":{"rendered":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/?page_id=7899"},"modified":"2025-11-19T18:23:39","modified_gmt":"2025-11-19T18:23:39","slug":"clinic-consent-forms","status":"publish","type":"page","link":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/clinic-consent-forms\/","title":{"rendered":"Clinic Consent Forms"},"content":{"rendered":"\n<p><style>\n        .form_addrres ul li{\n            justify-content: flex-end !important;\n    display: flex !important;\n    grid-gap: 10px !important;\n    margin-bottom: 2px !important;\n        }\n        .form_addrres ul li a{<span data-mce-type=\"bookmark\" style=\"display: inline-block; width: 0px; overflow: hidden; line-height: 0;\" class=\"mce_SELRES_start\">\ufeff<\/span>\n            color: #525252 !important;\n        }\n        .form_icon_box i{\n            color: #f37423 !important;\n        }\n        .border_class{\n            background: rgb(83,83,83);\nbackground: -moz-linear-gradient(90deg, rgba(83,83,83,1) 50%, rgba(243,116,35,1) 50%);\nbackground: -webkit-linear-gradient(90deg, rgba(83,83,83,1) 50%, rgba(243,116,35,1) 50%);\nbackground: linear-gradient(90deg, rgba(83,83,83,1) 50%, rgba(243,116,35,1) 50%);\nfilter: progid:DXImageTransform.Microsoft.gradient(startColorstr=\"#535353\",endColorstr=\"#f37423\",GradientType=1);\n            height: 5px;\n        }\n    <\/style><\/p>\n<section id=\"form_section\" class=\"my-3\">\n<div class=\"container\">\n<div class=\"row align-items-center\">\n<div class=\"col-6\">\n<div class=\"form_logo\"><img decoding=\"async\" class=\"img-fluid\" src=\"http:\/\/gorewayphysiotherapy.com\/goreway\/wp-content\/themes\/goreway\/assets\/img\/logo.png\" alt=\"logo\" width=\"270px\" \/><\/div>\n<\/div>\n<div class=\"col-6\">\n<div class=\"form_addrres\">\n <ul>\n                  <li>\n                     <a href=\"tel:+1 (905) 612-8222\">+1 (905) 612-8222<\/a>\n                     <div class=\"form_icon_box\"><i class=\"fa-solid fa-phone-flip\"><\/i><\/div>\n                  <\/li>\n                  <li>\n                     <a href=\"fax:+1 (905) 612-8752\">+1 (905) 612-8752<\/a>\n                     <div class=\"form_icon_box\"><i class=\"fa-solid fa-fax\"><\/i><\/div>\n                  <\/li>\n                  <li>\n                     <a href=\"mailto:gorewayphysio@gmail.com\">gorewayphysio@gmail.com<\/a>\n                     <div class=\"form_icon_box\"><i class=\"fa-solid fa-envelope\"><\/i><\/div>\n                  <\/li>\n                  <li>\n                     <a href=\"https:\/\/gorewayphysiotherapy.com\/\">https:\/\/gorewayphysiotherapy.com\/<\/a>\n                     <div class=\"form_icon_box\"><i class=\"fa-solid fa-globe\"><\/i><\/div>\n                  <\/li>\n                  <li>\n                     <a href=\"#\">7330 Goreway Drive, Unit 20\n                     Mississauga, ON L4T 4J2<\/a>\n                     <div class=\"form_icon_box\"><i class=\"fa-solid fa-location-dot\"><\/i><\/div>\n                  <\/li>\n               <\/ul>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/section>\n<section class=\"border_class\"><\/section>\n<div class=\"form_content my-3\">\n<div class=\"container\">\n<div class=\"row\">\n<div class=\"col-12\">\n<h3 class=\"text-center\">CLINIC CONSENT FORM<\/h3>\n<h4 class=\"text-center\" style=\"text-decoration: underline;\">Consent for Payment Policies<\/h4>\n<p>Goreway Physiotherapy services are covered by Extended Health plans, WSIB, MVA, &amp; OHIP. Payment is due when the services are provided. Many extended health plans cover full or part of the fees for our services and we do provide online direct billing to most insurance companies, however some plans don\u2019t (please discuss with front desk person for details before you receive services). Some plans do require to pay upfront and you will be provided with a receipt that you can submit to your insurance for reimbursement. Our front desk staff would be happy to assist you with any questions related to billing &amp; fee structure.<\/p>\n<p>\u2022 In the case of WSIB or Motor Vehicle Accidents claims we can submit our fees directly to the WSIB\/ Auto Insurance.<\/p>\n<p>\u2022 For OHIP eligibility Criteria- check with front desk staff.<\/p>\n<p>\u2022 For products (Custom orthotics, stockings, &amp; Brace) most insurance companies requires to pay upfront and we are more happy to assist you to process your claim.<\/p>\n<h4 class=\"text-center\" style=\"text-decoration: underline;\">Missed \/Cancellation &amp; No-Show Policy<\/h4>\n<p>Your appointment time is held for you. Please understand that a missed appointment or late cancellation disables another client from accessing our services. As a result, cancellations less than 24 hours (unless an emergency), missed appointments or no show will be subject to the full session fess. We understand that last minute changes in your schedule are impossible for you to avoid, please plan accordingly for us to fill the appointment slot. We will attempt to remind you of your appointment a day in advance. However, do not rely on these calls to keep track of your appointments. You are fully responsible to keep up your schedule time. Please be advised that our front desk staff will apply the fees according to the above criteria. Any issues or concerns regarding payment of the cancellation fees should be brought up with your physiotherapist and escalated to the clinic director if appropriate. There is one time leniency for missed appointments. Upon repeated missed appointments this fee will be charged. This fee is not billable or payable by insurance. Patient with more than 2 missed appointments in succession will be discharged from therapy and referred to their Primary Care Provider.<\/p>\n<h4 class=\"text-center\" style=\"text-decoration: underline;\">Late Arrivals<\/h4>\n<p>If you arrive late, your session may be shortened to accommodate other patients whose appointments follow yours. Depending upon how late you arrive, your therapist will then determine if there is enough time remaining to start a treatment. Regardless of the length of the treatment actually given, you will be responsible for the \u201cfull\u201d session. Out of respect and consideration to your therapist and other patient, please plan accordingly and be on time.<\/p>\n<p><strong>Billing Information<\/strong> Any outstanding payment is patient\u2019s responsibility and are due. You are ultimately responsible for any allowed charges not covered by your insurance company(s). it is your responsibility to provide Goreway Physiotherapy with correct information including insurance company name, policy and certificate numbers, &amp; ets. If any charges on your insurance policy such as carrier change, termination of coverage, its your responsibility to update it within a timely manner.<\/p>\n<p><strong> Past due accounts:<\/strong> If your account becomes past due, we may need to take necessary steps to collect this debt. This may include contacting the person listed as spouse \/ family member or emergency contact on your intake sheet. If we have to refer your account for collection, you agree to pay all of the collection cost which are incurred. If your outstanding account are submitted to collection agency or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record. In this case, you acknowledge that Goreway Physiotherapy will not be held responsible for this action.<\/p>\n<p>I have been informed of my financial responsibility and agree to the terms and conditions as stated on this form. I understand that my health insurance is a contractual agreement between my insurance career and me. It is therefore my responsibility to question my insurance company regarding delays in payment and\/ or denial of coverage, incorrect processing of claims by the insurance company as well as any requirements that may be included in my insurance policy coverage (i.e.referral requirement, coverage of amount \/ percentage, co-payment, and deductibles)<\/p>\n<h4 class=\"text-center\" style=\"text-decoration: underline;\">Consent for Personal Information<\/h4>\n<p>\u2022 I understand to provide me the goods and services Goreway Physiotherapy and Rehabilitation Centre will collect some personal information about me (e.g. home telephone number, address)<\/p>\n<p>\u2022 I have reviewed the Goreway Physiotherapy and Rehabilitation Centre\u2019s privacy policy about the collection, use and disclosure of the personal information, steps taken to protect the information and my right to review my personal information. I understand how the privacy policy applies to me. I have been given a chance to ask any questions about the privacy policy and they have been answered to my satisfaction.<\/p>\n<p>I understand that Goreway Physiotherapy may need to provide my physician, lawyer, employer, adjudicator of workplace safety and insurance board, insurance company, social worker, or caseworker any or all medical information and copies of clinical records maintained by the above facility directly related to my present medical condition and treatments there of.<\/p>\n<p>I understand and agree with the following: <br \/>\u2022 I would like to receive notice when it is time to review whether I need new goods or services. <br \/>\u2022 I would like to receive newsletters, greeting cards, &amp; other information mails from Goreway Physiotherapy and Rehabilitation Centre. <br \/>\u2022 I am consenting to phone\/ email communication for appointment reminders, to send invoices &amp; other related information pertaining to my visits. <br \/>\u2022 I understand that I may ask questions at any time, and that my consent may be withdrawn in writing at any future time. <br \/>\u2022 I understand that I am responsible for the payment of all fees associated with the service that is provided to me. <br \/>\u2022 I have read and understand the cancellation, No Show &amp; Late Arrivals Policy of Goreway Physiotherapy and I agree to abide by its terms. <br \/>\u2022 I have given chance to ask any question related to fees structure &amp; cancellation Policy<\/p>\n<\/div>\n<\/div>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f7903-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"7903\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/pages\/7899#wpcf7-f7903-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"7903\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f7903-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"text-center\">\n\t<div class=\"form-row text-center\">\n\t\t<div class=\"form-group col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-642\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" id=\"inputPatentname\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-642\" \/><\/span><br \/>\n<label for=\"inputPassword4\"><strong>Clients\/ Parents\/ Guardians Signature<\/strong><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p class=\" text-left text-bold\" style=\"font-weight:bold ;font-style: italic;\">Thank you for your Business & understanding !\n\t<\/p>\n\t<div class=\"col-md-12\">\n\t\t<p><a href=\"\" target=\"_blank\"><button type=\"button\" class=\"btn btn-danger\">Download PDF<\/button><\/a><br \/>\n<input class=\"wpcf7-form-control wpcf7-submit has-spinner btn btn-success\" type=\"submit\" value=\"Submit\" \/>\n\t\t<\/p>\n\t<\/div>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n<\/div>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>+1 (905) 612-8222 +1 (905) 612-8752 gorewayphysio@gmail.com https:\/\/gorewayphysiotherapy.com\/ 7330 Goreway Drive, Unit 20 Mississauga, ON L4T 4J2 CLINIC CONSENT FORM Consent for Payment Policies Goreway Physiotherapy services are covered by Extended Health plans, WSIB, MVA, &amp; OHIP. Payment is due when the services are provided. Many extended health plans cover full or part of the [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":6,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-7899","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/pages\/7899","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/comments?post=7899"}],"version-history":[{"count":4,"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/pages\/7899\/revisions"}],"predecessor-version":[{"id":7935,"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/pages\/7899\/revisions\/7935"}],"wp:attachment":[{"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/media?parent=7899"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}