Massage Therapy, including the application of Tape, Heat & Cold, Traditional Chinese therapies, Stretching & home exercise programs and lifestyle advice, has been reported to be an effective treatment for many forms of musculoskeletal pain, some headaches and other similar symptoms. The risk of injury or complications from Massage Therapy is much lower than that associated with many medical and other forms of treatment. The aim of the treatment is always to improve the patient’s health, however before undergoing treatment the patient should understand the relevant factors relating to it.
Declaration of Informed Consent
Declare that the information provided, and any relevant matters I mention during the course of examination and treatment, is true to the best of my knowledge.
I undertake to inform the therapist of any changes to my medical, psychological or physiological condition should they occur.
I consent to disrobe to a level of my own comfort, and undergo a visual and tactile examination, assessment and subsequent massage therapy and associated treatment/s (such as muscle releases, stretching, and therapeutic use of adhesive tape, heat, cold or vacuum) deemed appropriate, and explained to me by the therapist and agreed to by me prior to their commencement.
I consent to a digital photographic record being made (when requested by the therapist, my referring practitioner, sports trainer, or my insurer) of my initial condition, assessment, treatment and progress towards recovery. (delete if unacceptable)
I understand that:
1. Whilst protecting my privacy, the therapist may relocate my clothing or covering in order to access an area of my body for treatment (e.g. the buttocks & upper thigh, hips, chest or shoulders)
2. In a minority of cases the treatment may be unsuccessful, and I may be in the same condition as before treatment commenced.
3. Although uncommon, the treatment may make the condition worse.
4. Temporary soreness may occur for up to 48 hours following a treatment
5. The therapist will cease any treatment IMMEDIEIATELY on my request.
I further understand that all matters are fully confidential, but acknowledge that relevant information may be passed on to my referring health practitioner for reference or my health insurer in order to verify a claim for rebate.
I agree to pay all fees by cash, electronic funds transfer (EFTPOS), or cheque (payable to Remedial Action) immediately following each visit or treatment.
The privacy of your personal information is important to our clinic. We are committed to collecting, using and disclosing personal information responsibly and only to the extent necessary for the goods and services we provide.
Like all medical professionals, we collect, use and disclose personal information in order to serve our patients. The primary purpose for collecting personal information is to provide treatment.
Like most organizations, we also collect, use and disclose information for purposes secondary to our primary purposes. The most common examples of our related and secondary purposes is to invoice patients for goods or services that was not paid for at the time, to process credit card payments or to collect unpaid accounts.
The cost of goods/services provided by the organization to patients is often paid for by third parties (e.g., motor vehicle accident insurance, private insurance). These third party payers often have the patient’s consent or legislative authority to direct us to collect and disclose certain information in order to demonstrate patient entitlement to this funding.
Patients or other individuals we deal with may have questions about our goods or services after they have been received. We retain patient information for a mandatory minimum of ten years after the last contact.
PROTECTING PERSONAL INFORMATION
We understand the importance of protecting personal information. For that reason, we have taken the following steps:
• Paper information is either under supervision or secured in restricted area.
• Electronic hardware is either under supervision or secure in a restricted area at all times.
• Paper information is transmitted through sealed, addressed envelopes or boxes by reputable companies.
• Electronic information is transmitted either through a direct line or has identifiers removed or is encrypted.
• External consultants and agencies with access to personal information must enter into privacy agreements with me.
YOU CAN LOOK AT YOUR INFORMATION
With only a few exceptions, you have the right to see what personal information we hold about you.
We can help you identify what records we might have about you. We will also try to help you understand any information you do not understand (e.g., short forms, technical language, etc.). We reserve the right to charge a nominal fee for such requests.