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Home
Home
Services
Physiotherapy
Personal Injury Rehab Clinic
Pelvic Floor Physiotherapy
Sports Injuries
Pre/Post Surgical Rehabilitation
Custom Foot Orthotics
Neuropathy
Massage Therapy
Orthopaedic Manual Therapy
Chiropractic care
Chiropody foot care
Medical Acupuncture
Active Exercise Program
Home Care Physiotherapy
Fall Risk Assessment and Treatment
Intramuscular Stimulation (IMS)
Mobility Aids Assessment and Prescription
Bracing
About
About
Team
Testimonials
Insurance Companies
FAQ
Patients
GLA:D Program
Blog
Contact
Forms
Consent Form
Appointment Requests
COVID Form
Safety
signature test - Richmond Hill Physiotherapy, Sports, Massage RMT, Pain Relief, Injuries & Rehabilitation
Home
signature test
For ALL IN-CLINIC Patients, It is required to fill out this screening questionnaire for EACH VISIT to the clinic
Conscent Form
Name*
Email (if you want a copy)
Date of Birth
*
Which Therapist Are You Seeing Today?*
Devorah Eisenman BHK, RMT
Susan Patterson, RMT
Tien Dao, RMT
Which therapist will you be attending?
Devorah Eisenman BHK, RMT
Susan Patterson, RMT
Tien Dao, RMT
Other
*
I have requested assessment and/or treatment by the above Registered Massage Therapist (RMT) for treatment of the clinically relevant areas indicated below (please select ):
How did find out about this event?
Buttocks (gluteal Muscles)
Chest Wall Muscles
Upper Inner Thigh (s)
The RMT has explained the following to me and I fully understand the proposed assessment and/or treatment: • The nature of the assessment, including the clinical reason(s) for assessment of the above areas(s) and the draping methods to be used • The expected benefits of the assessment • The potential risks of the assessment • The potential side effects of the assessment • That consent is voluntary • That I can withdraw or alter my consent at any time I voluntarily give my informed consent for the assessment and/or treatment as discussed and outlined above.
Client Name/Guardian:
Declaration:
I have answered all the above questions honestly and truthfully
Signature
* Required
CONTACT US
How Can We Make Your Day Better?
Your Name (required)
Your Email (required)
Your Tel
Your Message
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