{"id":7906,"date":"2025-11-19T16:46:27","date_gmt":"2025-11-19T16:46:27","guid":{"rendered":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/?page_id=7906"},"modified":"2025-11-19T18:22:54","modified_gmt":"2025-11-19T18:22:54","slug":"physiotherapy-consent-form","status":"publish","type":"page","link":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/physiotherapy-consent-form\/","title":{"rendered":"Physiotherapy Consent Form"},"content":{"rendered":"\n<p><style>\n        .form_addrres ul li {\n            justify-content: flex-end;\n            display: flex;\n            grid-gap: 10px;\n            margin-bottom: 2px;\n        }\n\n        .form_addrres ul li a {\n            color: #525252;\n        }\n\n        .form_icon_box i {\n            color: #f37423;\n        }\n\n        .border_class {\n            background: rgb(83, 83, 83);\n            background: -moz-linear-gradient(90deg, rgba(83, 83, 83, 1) 50%, rgba(243, 116, 35, 1) 50%);\n            background: -webkit-linear-gradient(90deg, rgba(83, 83, 83, 1) 50%, rgba(243, 116, 35, 1) 50%);\n            background: linear-gradient(90deg, rgba(83, 83, 83, 1) 50%, rgba(243, 116, 35, 1) 50%);\n            filter: 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\">PHYSIOTHERAPY INFORMED CONSENT FORM<\/h3>\n<br \/>\n<h4>Please Read Carefully<\/h4>\n<p><strong>NOTE TO CLIENT:<\/strong> We want your informed consent. This means we want you to understand the services we hope to provide to you the cost involved, and what we do with personal information we obtain about you. If you have questions on any of this, please ask.<\/p>\n<p>I, the undersigned, hereby provide informed consent to the assessment and treatment plan prescribed by the attending Physiotherapist who examined me, assessed my condition and explained the treatment plan to me.<\/p>\n<p>\u2022 My treatment plan may include and but not limited to manual techniques, therapeutic exercise, modalities, acupuncture, taping as well as other techniques and procedures my treating therapist determines may improve function.<\/p>\n<p>\u2022 I understand that my treatment may change from time to time at my health professional\u2019s discretion.<\/p>\n<p>\u2022 I agree to provide you the relevant information regarding my condition. I understand that the treatments may be administered by the Physiotherapist or support personnel under the supervision of the physiotherapist.<\/p>\n<p>\u2022 I understand that the assessment and treatment may involve physical examination, manual therapy, therapeutic exercises, and\/or the use of modalities. These are designed to help diagnose, treat, and manage my condition. Without proper assessment and treatment, my condition may persist or worsen. While all procedures are performed with care, I acknowledge there may be minor risks such as soreness, bruising, fatigue, or temporary discomfort. I understand that potential benefits, risks, and alternatives will be discussed with me before treatment begins.<\/p>\n<p>\u2022 I must inform this office of any other practitioner (other than physicians) that I am currently seeing.<\/p>\n<p>\u2022 I must inform my physical therapist of any contagious or infectious condition that I might have. I understand that I need to express all my health concerns (both current and past to my therapist)<\/p>\n<p>\u2022 I understand that discomfort may occur during or after therapy sessions, and that the therapist may contact my physician to determine if any symptoms present potential risks; I also acknowledge that it is my responsibility to contact the clinic\u2019s therapist should I experience any unusual symptoms following treatment.<\/p>\n<p>\u2022 I understand that if any time I am not comfortable with, and \/ or do not understand the purpose of any treatment procedures I will ask the physiotherapist for further explanation\/ information. I understand that I may stop the assessment or treatment procedure at any time, during or after a session.<\/p>\n<p>\u2022 I understand that the clinic will send an initial assessment and follow-up report(s) as appropriate to the licensed practitioner who referred me to the clinic for treatment.<\/p>\n<p>\u2022 I have read, understood, and had opportunity to discuss the Client Information form I have read and fully understand all the above information and give my permission to be assessed and \/ or treated at Goreway Physiotherapy and Rehabilitation Centre.<\/p>\n<p>My signature below indicates my understanding of all the above information. I, hereby freely consent to participate in the physical and functional assessment and recommended treatment program delivered by those authorized in the clinic. If under 16 years of age, the following section of the consent form must be completed by a parent or guardian before treatment can be initiated:<\/p>\n<\/div>\n<\/div>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f7909-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"7909\">\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\/7906#wpcf7-f7909-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=\"7909\" \/><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-f7909-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div method=\"post\" class=\"text-center\">\n\t<div class=\"form-row text-center\">\n\t\t<div class=\"form-group col-md-6\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-952\"><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-952\" \/><\/span><br \/>\n<label for=\"inputPassword4\"><strong>Clients\/ Parent\/ Guardian\u2019s Signature <\/strong><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"form-group col-md-6\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"date-506\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date form-control\" id=\"inputDate\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-506\" \/><\/span><br \/>\n<label for=\"inputEmail4\"><strong>Date: <\/strong><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\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<\/p>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n<\/div>\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 PHYSIOTHERAPY INFORMED CONSENT FORM Please Read Carefully NOTE TO CLIENT: We want your informed consent. This means we want you to understand the services we hope to provide to you the cost involved, and what we do with [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":5,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-7906","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/pages\/7906","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=7906"}],"version-history":[{"count":3,"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/pages\/7906\/revisions"}],"predecessor-version":[{"id":7934,"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/pages\/7906\/revisions\/7934"}],"wp:attachment":[{"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/media?parent=7906"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}