Physiotherapy Informed Consent Form

1. All Physiotherapy treatments carried out in Faircape Health @ Tokai Estate are performed at the Physiotherapist’s discretion. All the necessary steps will be taken to eliminate and/or minimize any potential risks and/or disadvantages associated with any treatment.
2. In order to perform certain treatments, the Physiotherapist may need to uncover specific parts of the patient’s body and make physical contact with him/her. This will at all times be carried out in a Professional manner, protecting the privacy of the patient as far as possible.
3. The Physiotherapist may need to divulge certain personal and medical information regarding the patient to other attending practitioners and administrative staff concerned for purposes relating to the treatment or to process for statistical, epidemiology, managed health care, and payment purposes, which includes the sending of the account to the relevant third party payer if applicable. These practitioners and administrative staff will have access to the personal medical records on a
   “need-to-know” basis. Patient confidentiality will be protected at all costs, but absolute confidentiality cannot be guaranteed. As far as possible, the information will be dealt with in a confidential manner.
4. Tariffs charged are according to the guidelines of the South African Society of Physiotherapy, unless otherwise stipulated.
5. All PMB accounts will be sent electronically to your Medical Aid. However the Medical aid may not pay the full amount, and you will be liable for the remaining amount.
6. All private accounts must be settled on the day of treatment.
7. All accounts must be settled within 30 days from the date of account. Account queries must be settled within 14 days. You are personally responsible for payment and not your Medical Aid. Interest, as stipulated by the HPCSA, will be charged on accounts that have not been settled within 60 days. Should the account be handed over for collection, you will be held responsible for
   all costs incurred.
8. Should you have any questions, please contact the physiotherapist immediately. Contact details are available from the Faircape Health secretary.
9. We assure you of our professional service and treatment at all times.

1) Assessment:
Therapy will start with an assessment that includes the below to take place on pre-agreed dates:
● Intake Patient meeting. It will take approximately 15min to one hour.
● Assessment of Patient: a range of age-appropriate standardized assessments are used. The duration of the assessment depends on multiple factors such
as age, response to assessment tasks, and the assessments that need to be completed (Range: 1 to 4 hours – may be broken up into multiple
sessions).
● Feedback Patient meeting. The results of the assessment are discussed in detail and recommendations are made based on the assessment findings.
● Report

2) About Therapy:
Therapy consists of a carefully planned and graded treatment. Please remember that:
● The duration of therapy cannot be determined beforehand. Speed of progress is dependent on each individual Patient, the severity of the identified concerns, and the consistency of sessions.
● Generally, the time the Patient spends in therapy can be greatly reduced by the completion of activities at home (as recommended by your Therapist).

Please dress comfortably (tracksuit or shorts) as the sessions are physically active.
A reassessment will be done after one year of therapy if therapy has not been terminated before then. The assessment tasks will be completed over regular treatment sessions and the Therapist will give you feedback for which you will be charged the regular session charge and the “In depth Reassessment Fee”.
The Therapist reserves the right to terminate therapy due to irregular attendance.

3) Reports:
Progress reports will be issued as the medical aid or patient requests them.
A final report will always be issued when therapy is terminated. Reports will be charged at medical aid rates

4) Fees:
The Practice fees are subject to an annual increase, effective from 1 January. Should any alteration of fees be brought into effect, written notice will be provided via email. Professional fees are principally time based and are charged in respect of all time spent on each individual client. This includes therapy sessions, record keeping of sessions/consultations, preparation for therapy sessions and consultations, feedback and telephone calls with Patients or any other professional involved with the case.
NOTE: Although a session rate is fixed, different billing codes are used to make up the rate. For example, “Individual Therapy 45 minutes”: this rate is made up of multiple billing codes such as an individual treatment code (45-minute
session) and a recommendations code; or, individual treatment code (45-minute session), observations and screening, and Patient communication code. The separate billing codes align with the time spent with the Patient for the provision of comprehensive therapy services charged for. Services provided by the Practice will be reflected on an invoice rendered on/about the 26th of every month and
emailed to the Patient’s email addresses as provided on page 1 (“Invoice Delivery Date”). You can settle on the day or treatment. Should your condition be a Prescribed Minimum benefit we will apply directly to your medical aid.

PAYMENT IS DUE AND PAYABLE DIRECTLY AFTER YOUR APPOINTMENT AT RECEPTION

Should the receptionist in anyway not be able to process your payment, an invoice will be sent to you for immediate payment

Please note, assessment or progress reports will not be forwarded until your account is settled in full. If payment is not received by the end of the month, reminder notifications will be sent out. If payment is not received by the 10th of the following month, therapy will be immediately discontinued and will only resume once your account is paid in full.

The Practice reserves the right to terminate therapy due to non-payment without notice.
The Practice reserves the right to charge interest on overdue accounts. The interest charged will be at a rate determined in accordance with Section 1 (2) of the
Prescribed Rate of Interest Act, 1975. If accounts are paid within the same month as issued, interest will ordinarily not be applied.
If you neglect to settle your account, a third party will be contracted to recover outstanding monies. Any administrative or legal costs involved in the collection of monies owed will be for your account. Any and all legal costs will be recoverable on an attorney and own client scale. If you have any special circumstances that prevent you from paying, please let the Therapist know immediately so that a
payment plan can be arranged.

5) Confidentiality and express consent:
Every person that receives therapy in the Practice has the right to confidentiality (this means to have your personal information kept private, even from family members and other significant individuals). The Practice takes the
protection of personal information seriously as required in terms of the Protection of Personal Information Act No. 4 of 2014 (“POPIA”, as may be amended or substituted from time to time), as well as in terms of our role as a health care
provider. Your and our rights and obligations are set out in the Privacy Notice which you acknowledge, understand and accept (as attached). Nothing that you share with your Therapist will be passed on to anyone, unless:

● The law on medical aids forces the Practice to provide certain information to the medical aid. Your invoice will therefore include personal information, specific treatment codes and diagnostic codes.
● When we receive an order from a court to disclose your information, we have no choice but to provide it. Or when a specific law (legislation/regulation)
makes it compulsory to report things such as TB and cancer.
● Communication with other relevant health professionals, insofar as it is necessary and in the interests of the Patient. Signed consent will be obtained for this.

6) Cancellations:
Please inform the practice of cancellation at least 12 hours prior to the scheduled time. Late arrivals will be charged for in full and the Patient will receive therapy for the remaining duration of the scheduled session.
Failure to cancel sessions as set out above will result in an “Appointment Not Kept” fee of R300 being charged . Your medical aid will not reimburse you for this fee.

7) Domicilium Citandi et Executandi and Jurisdiction:
The respective parties choose as their domicilium citandi et executandi for the purposes of legal proceedings and for the purposes of giving or sending any notice provided for or necessary in terms hereof, the addresses as set out within
their details provided above on page 1. Any notices, formal communication and/or process (whether legal or otherwise) may be sent to the Email addresses
provided herein (or updated from time to time in writing) and where sent, shall be deemed to have been received and read by the recipient twenty-four hours after the Email was sent.
The parties consent to the jurisdiction of the Magistrates Court (or Small Claims Court where applicable) in for all legal proceedings.

8) Undertaking:
We understand that part of the assessment or treatment may require the use of video recording and we give the Practice permission to use video recording for the purpose of assessment, clinical observation, training, and record
keeping. This will be managed in terms of the Privacy Notice. We also understand that each patient will respond differently to therapy intervention and no timeframe or results can be guaranteed.

Indemnity, Release, and Waiver of Liability:

I, the Patient, recognize that therapy includes active physical exercise which can lead to injuries. I acknowledge that I will participate at my own risk and by signing this document, I indemnify Megan Bezuidenhout and Marchelle Lake and their respective employees and representatives working within the Practice from any and all loss, costs, claims, injury, damage, or liability sustained or incurred by myself resulting from my participation and/or resulting from any act or omission of any agent, employee or representative of the Practice.}

This document is to be read in conjunction with the information sheet titled “Dry Needling information”

I, the patient, do hereby give my consent for the performance of dry needling therapy by the physiotherapist named

At the physiotherapy practice/department of: Tokai Physiotherapy Inc

● I understand that I can withdraw my consent at any time
● I understand that the therapist is appropriately qualified and trained to perform the required therapy.
● The areas of the body that I consent to have dry needled are:

● I am satisfied that the technique has been fully explained to me, and that my concerns
● have been addressed and that my questions have been answered to my satisfaction. I have read the attached
information sheet called “Dry Needling information”, and am in a satisfactory position to weigh up the risks and
limitations of the technique as regards know side effects.
● I understand that the technique is performed within a rehabilitative framework and that I must follow instructions as
given by the physiotherapist.
● I hereby indemnify the therapist and the practice against any and all liability arising from the treatment described above
including unforeseen or unknown consequences.

Dry Needling Information Sheet:

Your physiotherapist has offered to treat you using a technique called “Dry Needling”. This information leaflet explains more about this
technique.

Dry Needling is a very successful medical treatment, which uses very thin needles without any medication (a dry needle) to achieve its aim. Dry
Needling is used to treat pain and dysfunction caused by muscle problems, headaches, and some nerve problems. It is not at all the same as
acupuncture. Acupuncture is part of Traditional Chinese Medicine, whereas dry needling is a western medicine technique, which needs to have
a medical diagnosis. There is a clear scientific understanding of dry needling, which does not depend on any religious underpinnings. Dry Needling works by changing the way your body senses pain (neurological effects), and by helping the body heal stubborn muscle spasms associated with trigger points (myofascial effects). There are additional electrical and chemical changes associated with dry needling therapy,
which assist in the healing process. It is important to see the needles as just one part of your overall rehabilitative treatment. Dry needling is not a miracle cure – it is a normal part of physiotherapy. It is vital that you do the exercises and follow the advice your therapist gives you in conjunction with the needling for optimal recovery. Your therapist has been specifically trained in the various needling techniques. The therapist will choose a length and thickness of needle
appropriate for your condition and your body size, and then insert it through the skin at the appropriate place. You will feel a small pinprick.
Depending on the type of needle technique chosen by your therapist, you may also feel a muscle ache and a muscle twitch. These are all
normal and good sensations, and mean that you will experience good relief from your symptoms. In general, there is very little risk associated
with this technique if performed properly by a trained physiotherapist. You may have a little bruising around the needle site, much the same as
you would with any injection. On rare occasions, people may feel very happy, tearful, sweaty or cold. These symptoms all fade quickly. Fainting may occur in a very small
minority of people. There are no lasting ill effects of these side effects. If you are being treated in the shoulder, neck or chest area, there is an
additional risk that involves your lung. If the lung itself is punctured, you may develop a condition called a pneumothorax (air in the space
around the lung). This is a rare but serious problem, and you should go directly to a hospital casualty department without panicking if it occurs.
The symptoms of this event include shortness of breath which gets worse, sudden sharp pain each time you breathe in, a bluish tinge to your
lips, and an inability to “catch your breath”. The treatment is very successful for this rare but possible complication.
If you are happy to continue with the therapy as suggested by your therapist, and have asked any questions that you may want to, then please
sign the consent form attached to this page, and hand it to your physiotherapist. Please keep this information page for your own records.