{"id":620,"date":"2025-10-25T22:39:16","date_gmt":"2025-10-26T02:39:16","guid":{"rendered":"https:\/\/rmtandrac.com\/therapist\/?page_id=620"},"modified":"2025-10-25T22:49:31","modified_gmt":"2025-10-26T02:49:31","slug":"consent-to-treatment-sensitive-areas","status":"publish","type":"page","link":"https:\/\/rmtandrac.com\/therapist\/consent-to-treatment-sensitive-areas\/","title":{"rendered":"Consent to Treatment Sensitive Areas"},"content":{"rendered":"<style id=\"wpforms-css-vars-586-block-3f3011c0-72a4-486d-9497-3d6f3b3f2d75\">\n\t\t\t\t#wpforms-586.wpforms-block-3f3011c0-72a4-486d-9497-3d6f3b3f2d75 {\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-3f3011c0-72a4-486d-9497-3d6f3b3f2d75 wpforms-render-modern\" id=\"wpforms-586\"><form id=\"wpforms-form-586\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"586\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/therapist\/wp-json\/wp\/v2\/pages\/620\" data-token=\"d8a2629c8c3f6dfda35fe6df4e368526\" data-token-time=\"1776626039\"><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\">\t\t<div id=\"wpforms-586-field_1-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"1\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-586-field_1\" >(SDM) osteopath) or<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-586-field_1\" class=\"wpforms-field-medium\" name=\"wpforms[fields][1]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-586-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-50\"><div id=\"wpforms-586-field_5-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"5\"><div id=\"wpforms-586-field_5\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-586-field_5-error\"><h4>I,<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-586-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-586-field_4\">Name of patient or the substitute decision-maker (SDM) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-586-field_4\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-586-field_4-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-586-field_7-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"7\"><div id=\"wpforms-586-field_7\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-586-field_7-error\"><p><strong>consent to have<\/strong><\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-586-field_25-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"25\"><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-586-field_25\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][25][first]\" aria-errormessage=\"wpforms-586-field_25-error\" required><label for=\"wpforms-586-field_25\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-586-field_25-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][25][last]\" aria-errormessage=\"wpforms-586-field_25-last-error\" required><label for=\"wpforms-586-field_25-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-586-field_9-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"9\"><div id=\"wpforms-586-field_9\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-586-field_9-error\"><p><strong>perform the following treatment on me:<span class=\"Apple-converted-space\">\u00a0<\/span><\/strong><\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-586-field_10-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-586-field_10\"> Describe specific treatment or specific plan of treatment (e.g., massage, acupuncture or osteopath)<\/label><textarea id=\"wpforms-586-field_10\" class=\"wpforms-field-medium\" name=\"wpforms[fields][10]\" aria-errormessage=\"wpforms-586-field_10-error\" ><\/textarea><\/div><div id=\"wpforms-586-field_12-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"12\"><div id=\"wpforms-586-field_12\" class=\"wpforms-field-large wpforms-field-row\" aria-errormessage=\"wpforms-586-field_12-error\"><p><strong>*If treatment includes sensitive areas, I consent to have the practitioner provide assessment and\/or treatment of the areas indicated below:\u00a0<\/strong><\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-586-field_11-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"11\"><fieldset><legend class=\"wpforms-field-label\">please check the appropriate box(es)<\/legend><ul id=\"wpforms-586-field_11\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-586-field_11_1\" name=\"wpforms[fields][11][]\" value=\"Upper and inner thigh\" aria-errormessage=\"wpforms-586-field_11_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-586-field_11_1\">Upper and inner thigh<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-586-field_11_2\" name=\"wpforms[fields][11][]\" value=\"Buttocks\" aria-errormessage=\"wpforms-586-field_11_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-586-field_11_2\">Buttocks<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-586-field_11_5\" name=\"wpforms[fields][11][]\" value=\"Breasts\" aria-errormessage=\"wpforms-586-field_11_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-586-field_11_5\">Breasts<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-586-field_11_6\" name=\"wpforms[fields][11][]\" value=\"Chest wall muscles\" aria-errormessage=\"wpforms-586-field_11_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-586-field_11_6\">Chest wall muscles<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-586-field_13-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"13\"><div id=\"wpforms-586-field_13\" class=\"wpforms-field-large wpforms-field-row\" aria-errormessage=\"wpforms-586-field_13-error\"><p>I acknowledge the practitioner has explained the following to me:<\/p>\n<ul>\n<li>the nature of the treatment, as set out above<\/li>\n<li>if applicable, the clinical reason(s) for the assessment of the above sensitive area(s) and the draping methods to be used the expected benefits of the treatment<\/li>\n<li>the material risks of the treatment<span class=\"Apple-converted-space\">\u00a0<\/span><\/li>\n<li>the material side effects of the treatment<\/li>\n<li>the alternatives to having the treatment<span class=\"Apple-converted-space\">\u00a0<\/span><\/li>\n<li>the likely consequences of not having the treatment<\/li>\n<\/ul>\n<p>I acknowledge that my practitioner cannot guarantee the results of the proposed treatment.<\/p>\n<p>I acknowledge that I have informed my practitioner about my relevant health history, including whether I have any allergies, metal implants, if I suffer from any type of major bleeding disorder, if I use a pacemaker, or if I have any infectious viruses or diseases.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p>I understand that my consent is voluntary, and I have the right to withdraw my consent to the treatment at any time.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p>I understand that the fees charged for my treatment are not covered under OHIP and must be covered in full by myself or through third party insurance. I am responsible for the full and prompt payment after services have been rendered. I acknowledge that my practitioner has explained the applicable fees to me.<\/p>\n<p><b>I acknowledge that I have discussed the content of this form with my practitioner. I acknowledge that I have asked any questions I may have and received answers I understand.<\/b><\/p>\n<p>By signing this form, I give my informed consent for the treatment set out above.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-586-field_14-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"14\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-586-field_15-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-586-field_15\">Signature of Patient\/SDM: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-586-field_15\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][15]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-586-field_15-error\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-586-field_15-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 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-586-field_16-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-586-field_16\">Date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-586-field_16\" 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][16][date]\" aria-errormessage=\"wpforms-586-field_16-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-50\"><div id=\"wpforms-586-field_26-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-586-field_26\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-586-field_26\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][26]\" spellcheck=\"false\" aria-errormessage=\"wpforms-586-field_26-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><div id=\"wpforms-586-field_17-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"17\"><div id=\"wpforms-586-field_17\" class=\"wpforms-field-large wpforms-field-row\" aria-errormessage=\"wpforms-586-field_17-error\"><p><strong>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.<\/strong><\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-586-field_18-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"18\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-586-field_19-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-586-field_19\">Practitioner\u2019s Signature:<\/label><input type=\"text\" id=\"wpforms-586-field_19\" class=\"wpforms-signature-input wpforms-screen-reader-element\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][19]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-586-field_19-error\" ><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-586-field_19-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 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-586-field_20-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-586-field_20\">Date<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-586-field_20\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][20][date]\" aria-errormessage=\"wpforms-586-field_20-error\" ><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><\/div><script>\n\t\t\t\t( 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