{"id":616,"date":"2025-10-25T22:37:17","date_gmt":"2025-10-26T02:37:17","guid":{"rendered":"https:\/\/rmtandrac.com\/therapist\/?page_id=616"},"modified":"2025-10-25T22:49:14","modified_gmt":"2025-10-26T02:49:14","slug":"consent-for-massage","status":"publish","type":"page","link":"https:\/\/rmtandrac.com\/therapist\/consent-for-massage\/","title":{"rendered":"Consent for Massage"},"content":{"rendered":"<style id=\"wpforms-css-vars-578-block-c07f0bbb-56a5-4391-a787-cf40db3a95a3\">\n\t\t\t\t#wpforms-578.wpforms-block-c07f0bbb-56a5-4391-a787-cf40db3a95a3 {\n\t\t\t\t--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-c07f0bbb-56a5-4391-a787-cf40db3a95a3 wpforms-render-modern\" id=\"wpforms-578\"><form id=\"wpforms-form-578\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"578\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/therapist\/wp-json\/wp\/v2\/pages\/616\" data-token=\"29c5f5a3b237838c1f02e35e5df1d23a\" data-token-time=\"1776625951\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-578-field_1-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"1\"><div id=\"wpforms-578-field_1\" aria-errormessage=\"wpforms-578-field_1-error\"><h1> Patient Informed Consent to Treatment <\/h1><h1><\/h1><\/div><\/div><div id=\"wpforms-578-field_2-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"2\"><div id=\"wpforms-578-field_2\" class=\"wpforms-field-large wpforms-field-row\" aria-errormessage=\"wpforms-578-field_2-error\"><p>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.<\/p>\n<p>I understand that my treatment may change from time to time, and the necessary functional abilities test may be performed at my health professional\u2019s discretion.<\/p>\n<p>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.<strong> I understand that written authorization will be obtained prior to any <\/strong><strong>release of information, except when required by a court of law.<\/strong><\/p>\n<p>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.<\/p>\n<p>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.<\/p>\n<p>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.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-578-field_3-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"3\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-578-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-578-field_4\">Patient Name: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-578-field_4\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-578-field_4-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-578-field_5-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-578-field_5\">Patient Signature: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-578-field_5\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][5]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-578-field_5-error\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-578-field_5-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 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class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-578-field_6\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][6][date]\" aria-errormessage=\"wpforms-578-field_6-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-578-field_26-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-578-field_26\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-578-field_26\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][26]\" spellcheck=\"false\" aria-errormessage=\"wpforms-578-field_26-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><\/div><\/div><\/div><\/div>\t\t<div id=\"wpforms-578-field_7-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"7\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-578-field_7\" >Layout Email Patient<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-578-field_7\" class=\"wpforms-field-medium\" name=\"wpforms[fields][7]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-578-field_19-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"19\"><fieldset><legend class=\"wpforms-field-label\">Practitioner Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-578-field_19\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][19][first]\" aria-errormessage=\"wpforms-578-field_19-error\" required><label for=\"wpforms-578-field_19\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-578-field_19-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][19][last]\" aria-errormessage=\"wpforms-578-field_19-last-error\" required><label for=\"wpforms-578-field_19-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-578-field_12-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"12\"><div id=\"wpforms-578-field_12\" class=\"wpforms-field-large wpforms-field-row\" aria-errormessage=\"wpforms-578-field_12-error\"><p><i>By signing this form, I acknowledge that I have reviewed the form with the patient (or substitute decision-maker) and have answered the patient\u2019s (or substitute decision-maker\u2019s) questions.<\/i><\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-578-field_7-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-578-field_7-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-578-field_7-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"578\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/rmtandrac.com\/therapist\/wp-json\/wp\/v2\/pages\/616\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-578\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/rmtandrac.com\/therapist\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"template-parts\/page-left-sidebar.php","meta":{"footnotes":""},"class_list":["post-616","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/rmtandrac.com\/therapist\/wp-json\/wp\/v2\/pages\/616","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/rmtandrac.com\/therapist\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/rmtandrac.com\/therapist\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/rmtandrac.com\/therapist\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/rmtandrac.com\/therapist\/wp-json\/wp\/v2\/comments?post=616"}],"version-history":[{"count":1,"href":"https:\/\/rmtandrac.com\/therapist\/wp-json\/wp\/v2\/pages\/616\/revisions"}],"predecessor-version":[{"id":617,"href":"https:\/\/rmtandrac.com\/therapist\/wp-json\/wp\/v2\/pages\/616\/revisions\/617"}],"wp:attachment":[{"href":"https:\/\/rmtandrac.com\/therapist\/wp-json\/wp\/v2\/media?parent=616"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}