Terms of Treatment
It is important here at Pelvic Physio by Laura that we receive your informed consent before proceeding with evaluation and treatment. The term “informed consent” means that the potential risks, benefits, and alternatives of therapy evaluation and treatment have been explained to you. An explanation of the nature of a pelvic physiotherapy appointment, benefits, risks and alternatives to treatment are outlined below.
I acknowledge and understand that I have been referred for evaluation and treatment of pelvic floor dysfunction. Pelvic floor dysfunctions includes, but is not limited to; urinary or fecal incontinence, difficulty with bowel, bladder or sexual functions, painful scars after childbirth or surgery, persistent sacroiliac or low back pain, or pelvic pain conditions.
I understand that to evaluate my condition it may be necessary, initially and periodically, to have my therapists perform an internal pelvic floor muscle examination. This examination is performed by observing and/or palpating the perineal region including the vagina and/or rectum. This evaluation will assess skin condition, reflexes, muscle tone, length, strength and endurance, scar mobility and function of the pelvic floor region. I will have the opportunity to give/revoke my consent at each treatment session. I understand that I can still participate in a pelvic floor physiotherapy examination and treatment without an internal pelvic floor muscle examination, if I chose not to provide consent for that portion of the assessment. Treatment may include, but is not limited to the following: observation, palpation, use of vaginal weights, vaginal or rectal sensors for biofeedback and/or electrical stimulation, ultrasound, heat, cold, stretching and strengthening exercises, soft tissue and/or joint mobilization and educational instruction.
Potential risks: I acknowledge that I may experience an increase in my current level of pain or discomfort, or an aggravation of my existing injury. This discomfort is usually temporary; if it does not subside in 1-3 days, I agree to contact my therapist.
Potential benefits: I acknowledge that benefits to treatment may include an improvement in my symptoms and an increase in my ability to perform my daily activities. I may experience increased strength, awareness, flexibility and endurance in my movements. I may experience decreased pain and discomfort. I should gain a greater knowledge about managing my condition and the resources available to me.
Alternatives: I acknowledge that if I do not wish to participate in the therapy program, I will discuss my medical, surgical or pharmacological alternatives with my physician or primary care provider.
Release of medical records: I authorize the release of my medical records to my physicians/primary care provider or insurance company. I understand that the clinic does not share personal information with any agencies not directly related to my physiotherapy treatment care and does not provide patient’s information to solicitors.
Cooperation with treatment: I understand that in order for therapy to be effective, I must come as scheduled unless there are unusual circumstances that prevent me from attending therapy. I agree to cooperate with and carry out the home program assigned to me. If I have difficulty with any part of my treatment program, I will discuss it with my therapist.
Cancellation Policy: I understand that if I cancel more than 24 hours in advance, I will not be charged. I understand that if I cancel less than 24 hours in advance, I will pay the full appointment fee.
No warranty: I understand that the physical therapist cannot make any promises or guarantees regarding a cure for improvement in my condition. I understand my therapist will share with me her opinions regarding potential results of physical therapy for my condition and will discuss all treatment options with me before I consent to treatment.
***If you are pregnant, have an infection of any kind, have vaginal dryness, are less than 6 weeks postpartum or post-surgery, have severe pelvic pain, sensitivity to lubricant, vaginal creams or latex, please inform the therapist prior to the pelvic floor assessment.
By proceeding with services provided by Laura Holland, I have informed my therapist of any condition that would limit my ability to have an evaluation or be treated. I hereby request and consent to the evaluation and treatment to be provided.
The College of Physiotherapists of Ontario has strict policies to ensure that your privacy is always protected throughout your course of treatment. We collect your personal medical information to ensure that we are providing you with the most safe and effective physiotherapy services. This information is always collected and distributed (where necessary) with your consent. Distribution of information occurs only for billing purposes (in the event an insurance company attempts to verify treatment attendance), treatment purposes and/or for professional review. Your information is kept for a minimum of 8 years and a maximum of 10 years in accordance with the College of Physiotherapists of Ontario. In order to protect your personal information, we have taken the following steps to ensure your privacy:
*We do not share personal information with any agencies not directly related to your care and we do not provide patient information to solicitors.
Revision Date – February 21, 2021
WHAT IS PERSONAL INFORMATION?
“Personal Information” is any information which can identify an individual or through which an individual’s identity can be deduced, and which is disclosed to us or which we create within the context of our relationship with the individual. Please note that Personal Information does not include information which does not relate to an identified individual nor does it include an individual’s name, title, business address or business telephone number (i.e. “business card information”).
WHY DOES THE COMPANY COLLECT PERSONAL INFORMATION?
In serving the needs of the Company and its employees, contractors and customers, it is important that the Company has accurate information. The Company may collect Personal Information in order to:
• establish your identity;
• understand your needs for, and determine your suitability for, products and services;
• provide services to you and process payments for your account;
• inform you of new products and services;
• establish and maintain an employment or contractor relationship; and
• adhere to legal requirements.
HOW WILL YOUR PERSONAL INFORMATION BE USED?
The Company may use Personal Information in order to:
• personalize your experience and allow the Company to deliver the type of content and product offerings in which you are most interested;
• improve our website in order to better serve you;
• administer, maintain and improve our relationship with you;
• comply with legal, regulatory and other obligations; and
• carry out our business operations.
WHEN MIGHT PERSONAL INFORMATION BE DISCLOSED?
The Company may disclose Personal Information in order to:
• administer and maintain any employment/contractor relationship;
• administer and maintain benefits and payroll;
• make hiring decisions;
• submit quotes or proposals to prospective customers or clients; and
• explore and/or undertake corporate opportunities, including a merger, acquisition, amalgamation, IPO, reorganization or sale of the Company, including the due diligence process and the transfer of information through to closing of any such transaction.
We do not share personal information with any agencies not directly related to your care and we do not provide patient information to solicitors.
HOW DOES THE COMPANY COLLECT YOUR PERSONAL INFORMATION?
We collect your Personal Information at the time you become a new customer, client, supplier, employee or contractor of the Company and thereafter when we communicate with you. For example, we collect your Personal Information through:
• your responses to surveys or forms or interaction with webpages on our Site;
• your discussions with our employees and contractors; and
• your visits to our website and/or intranet.
HOW DOES THE COMPANY PROTECT PERSONAL INFORMATION?
Safeguards, security systems and processes are in place to protect your information against unauthorized access, disclosure, use, or modification, whether on-site or off-site. Your Personal Information is contained behind secured networks and is only accessible by a limited number of persons who have been designated with such authority and only to the extent necessary to accomplish the objectives we’ve described above, or to the Company’s relevant benefits. All transactions are processed through a gateway provider and are not stored or processed on our servers.
Furthermore, the Company agrees to take reasonable steps to maintain appropriate physical, technical and administrative security to help prevent loss, misuse, unauthorized access, disclosure or modification of Personal Information. Please note that the Company is not liable to you for any damages resulting from unauthorized access of Personal Information as long as reasonable precautions have been met. The right to determine what “reasonable precautions” are remains solely with the Company. In the event that it is determined that the Company did not take reasonable precautions in relation to your Personal Information, you agree that the maximum cumulative aggregate liability of the Company is limited to fifty dollars ($50.00) or the licensing fees paid in the current year of the term as specified in the Client Order, whichever is greater.
HOW LONG WILL THE COMPANY RETAIN YOUR INFORMATION?
We retain your information for only so long as is necessary for the purposes for which it has been collected. Your Personal Information will be destroyed once it is no longer needed by us and once all requirements at law have been met.
HAVE YOU CONSENTED?
HOW CAN YOU ACCESS YOUR PERSONAL INFORMATION?
Your Personal Information, hard copy or electronic, is accessible to you. However, if your information is combined with information of others, you will not be granted access to such information unless we are able to segment your Personal Information. If your request for Personal Information entails a significant cost due to time, resources or copying, there may be a charge.
Our website may employ the use of “cookies”. A “cookie” is a small line of data that is sent to your Internet browser from a web server and stored on your computer’s hard drive. Cookies can track how and when you use a site. A cookie does not damage your system and identifies your browser, not you personally. If you do not wish to receive a cookie, you should use the options in your web browser to disable the function. If you have any questions or concerns about this policy, or should you wish to review your Personal Information, please contact Laura Holland; [email protected]
Please refer to specific clinic cancellation policies for in-person visits.