Consent for Treatment
This form must be read prior to treatment where the practitioner utilises manipulative based therapy including chiropractic joint manipulation and soft tissue based therapies. If you would like to discuss this, please do so prior to signing patient intake form.
Listed below are the treatment modalities which may/may not be used in the treatment of your stated complaint or injury:
Spinal and joint manipulative therapy
Dry Needling
Massage and soft tissue stretching
Sports taping and/or bracing
Rehabilitative exercises and or exercise pattern re-training
Nutritional advice
Interferential/TENS
Granted, there are associated risks with the aforementioned modalities and hence, if you DO NOT wish to undergo a particular type of treatment, please INFORM your practitioner.
The possible risks associated with the available treatment modalities include:
Aggravation of an existing condition or of the injury
Bruising
Sleepy, itchy or light headedness
Fainting
Fracture
Sprain/strain to ligament, joint capsule, muscle or tendon
Stroke or stroke-like symptoms
Spinal cord trauma
Rupture of disc
Infection
If you have experienced these symptoms/aggravations in the past due to a treatment modality please ensure that you INFORM your practitioner.
By agreeing to our T&Cs and privacy policy you hereby acknowledge: the possible risks as outlined above; Balance Health and Performance Pty Ltd is a company which provides a primary healthcare service; give consent to the primary healthcare practitioners endorsed by Balance Health and Performance Pty Ltd; acknowledge that this consent applies to all affiliated members of Balance Health and Performance Pty Ltd; understand your clinical file will be accessible only to the staff and practitioners of Balance Health and Performance Pty Ltd; maintain your clinical file is private and confidential with no part of which can be released to a third party without your prior written approval.
Please note 6 hours’ notice is required for cancellations to avoid potential cancellation fees
Please understand that accounts are to be settled at the time of your appointment