Tele-health Consent Form - Tawa Physiotherapy

Tawa Physical Therapy Intake Consent Form

Name
First Last
Are You Located In Edmonton?
- Yes
- No
Local Emergency Numbers: If you are outside of Edmonton city limits, please indicate the following local emergency telephone numbers for your area:
Police Phone Number
Ambulance Services Phone Number
Fire Department Phone Number
Tele-Rehabilitation Consent:*
- I certify that the above information is correct to my knowledge
Privacy and Sharing of Information*
- I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission. Tele-rehabilitation appointments will not be recorded, and as such visits shall not be recorded by the clinic, therapist, or client. We are using Zoom for Healthcare as a premium, paid version of the Zoom platform with no personal client data stored on this platform.
Cancellation Fee Policy*
- I am aware and I agree that a late cancellation or missed visit leaves a hole in the therapist’s day that could have been filled by another patient. As such, 4 hours notice is required for any cancellation or change to my appointment. If I provide less than 4 hours notice for cancellation or miss my appointment, I will be charged a $40 cancellation fee.
Consent to Tele-Rehabilitation Assessment and Treatment*
My healthcare provider has explained to me how the video conferencing technology will be used to affect such a consultation. I understand that this consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my healthcare provider. I understand there are potential risks to this technology, including interruption, unauthorized access and technical difficulties. I understand that my healthcare provider or myself can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. I have had the alternatives to a telemedicine consultation explained to me, and in choosing to participate in a telemedicine consultation, I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care provider. The physiotherapists at Tawa Physical Therapy & Sports Injury Clinic are licensed to practice only on clients that are physically located within the province of Alberta at the times of their appointments. The risks involved with Telemedicine include the potential unintentional release of private information due to the complexities and abnormalities involved with the internet. Viruses, Trojans, and other involuntary intrusions have the ability to grab and release information you may desire to keep private. Furthermore, there is the risk of being overheard by anyone near you if you do not place yourself in a private area and are open to other’s intrusion. The advantages of Telemedicine include the benefit of continuity of care in the absence of your clinician as well as the ability to be treated from any location at any time.
- I consent to Tele-Rehabilitation Assessment and Treatment. I am and will be physically located in the province of Alberta for my appointments.
Consent to Billing and Payment Policy*
All appointments are to be paid over the phone via credit card and/or via direct billing to your insurance provider. For services funded by third parties such as Alberta Health Services or the WCB, your funded tele-rehabilitation interaction will be used in place of an in-person visit. At the time of booking your appointment, your credit card information will be taken, but not charged, to finalize your booking If you cancel your appointment in less than 4 hours prior to your appointment, you are subject to our Cancellation Fee Policy.
- I have read and consent to the Billing and Payment Policy
Legal Age
I am 18 years of age or older on the first day of treatment by Tawa Physical Therapy
- Yes
- No
Name of Legal Guardian*
First Last
Date*
MM slash DD slash YYYY