I have received information about the massage therapy treatment as well as the nature of treatment, benefits, risks, side effects, alternative courses of action, consequences of not having the treatment, my right to stop or modify the treatment at any time, instruction on dressing/undressing procedures, instruction on positioning/covering during the treatment, hydrotherapy applications, remedial exercises program, contraindications (if present), duration of the assessment and the treatment, and the cost.

I understand that my treatment may change from time to time, and the necessary functional abilities test may be performed at my health professional’s discretion.

I also understand that results are not guaranteed. All information in my file will be kept confidential, although the file will be shared among the treatment therapists in this facility. The shaing of the file will improve the flow of information among the professionals to ensure the utmost quality care. I understand that written authorization will be obtained prior to any release of information, except when required by a court of law.

I agree that my personal data is accurate and have, or will, provide all necessary and accurate information. Should this information be changed I am personally responsible for notifying the clinic to update my personal data.

I agree and fully understand that my treatments are not covered by OHIP. I am willing to pay for all treatments not covered by my Extended Health Care Insurance Company and/or Workplace Safety Insurance Board and/or my Auto Insurance Company.

I have read the above consent. I have also had the opportunity to ask questions about its content, and by signing below I agree to the above named procedures and tests. I intent this consent to cover the entire course of treatment for my present condition and any future condition(s) for which I seek treatment.

By signing this form, I acknowledge that I have reviewed the form with the patient (or substitute decision-maker) and have answered the patient’s (or substitute decision-maker’s) questions.