Note: Please take a few moments to read the Consent Form that you will be asked to sign a printed copy of at the clinic
Informed Consent to Osteopathic Manual Treatment (to read only)
I certify that the information provided in my Medical History is, to my knowledge, exact. I recognize and admit my responsibility for all information not declared regarding my health past and present. I consent to communicating with my physician, if needed, since his medical information may be necessary for my care. I have had the opportunity to ask questions regarding my Medical History and I understand that the clinic "In Good Hands" is under strict legal obligation to respect the confidentiality of my personal information.
I (the undersigned) hereby consent to my Therapist to treat me with osteopathic manual treatments including such assessments, examinations and techniques, which may be recommended by my Therapist. I understand that the Osteopathic Manual Treatment services provided by "In Good Hands" clinic aim to reduce pain caused by fascial restrictions, muscle tension and tethered nerves, increase joint mobility, improve cardiovascular and lymphatic circulation as well as provide a positive experience.
The general benefits of osteopathy, its contraindications or precautions and the care plan (treatment) have been explained to me in a clear fashion. I clearly understand that osteopathic manual treatments are not a substitute for a medical examination or medications. It is recommended that I attend my personal physician for any ailments that I may be experiencing. I acknowledge that the Therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder nor prescribes medication. I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment. I acknowledge that with any treatment there can be risks and those risks have been explained to me and I assume those risks. I have had the opportunity to ask questions and receive answers concerning my care plan I am aware of the fees and policies of the clinic "In Good Hands. and I certify that I have made a clear and informed choice concerning my evaluation and the care plan chosen. I have read the above noted consent and I have had the opportunity to question the contents of my care plan.
I am aware of the fees and policies of the clinic "In Good Hands" and I certify that I have made a clear and informed choice concerning my evaluation and the care plan chosen.
By signing this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such additional treatment(s) as proposed by my Therapist from time to time, to deal with my physical condition and for which I have sought treatment. I understand that at any time I may withdraw my consent and treatment will be stopped.
Full disclosure of Medical History
I acknowledge and understand that the Therapist must be fully aware of my existing medical conditions. I have completed my Medical History form as provided by my Therapist and disclosed to the Therapist all of those medical conditions affecting me. It is my responsibility to keep the Therapist updated on my medical history. The information I have provided is true and complete to the best of my knowledge. I recognize and admit that it is my responsibility for any oversight to declare my state of health past and present.
Client Name (printed):____________________ Client signature: ____________________________
(If applicable) Parent/Guardian Name (printed):________________ Parent/Guardian signature:_____________
Date Signed:_________________________________
