I consent to be assessed and treated by a Registered Physiotherapist in person and or virtually. I consent that my health records at HigherGround will be accessible to all my healthcare practitioners involved in my treatment and I understand that HigherGround is the Health Information Custodian. My rehabilitation plan which may include manual therapy (joint mobilizations/manipulation), strengthening exercises, stretching exercises, ultrasound, interferential current, and or taping will be discussed with me and I will be made fully aware of the benefits, risks and possible side effects of the proposed treatments, alternative courses of action and consequences of not having treatment. I understand that my consent to treatment/ assessment in person or virtually can be withdrawn at any time verbally, by email or other written communication.

I acknowledge that in consenting to having the Registered Physiotherapist provide virtual services through Zoom, Skype, Microsoft Teams, FaceTime, etc,

I am aware of the following:

1. Risks of using electronic communication

The Registered Physiotherapist will use reasonable means to protect the security and confidentiality of the information sent and received using electronic communications, because of the risks outlined below, the Registered Physiotherapist cannot guarantee the security and confidentiality of electronic communications:

Electronic communications can introduce malware into a computer system, and potentially damage or disrupt the computer, networks and security settings

Electronic communications are subject to disruptions beyond the control of the Registered Physiotherapist that may prevent them from providing services

Videoconferencing using no cost, publicly available services may be more open to interception than other forms of videoconferencing.

2. Conditions of using Electronic Communications

Electronic communication may not be an appropriate substitute for some services that the Registered Physiotherapist offers.

Prior to the commencement of the provision of services by the Registered Physiotherapist through electronic communications, the Registered Physiotherapist and the patient will establish an emergency protocol to address the following:

Steps to be followed in the event of a technical issue that causes a disruption in the services that are being provided by the Registered Physiotherapist;

Steps to be followed in the event of a medical emergency that occurs during the provision of services

The patient will inform the Registered Physiotherapist of any changes in the patient’s email address, phone number, emergency contact or other information necessary to communicate electronically.

I acknowledge that I have read and fully understand the risks, limitations, conditions of use and instructions for in person and virtual physiotherapy services provided by the Registered Physiotherapist. I understand and accept the risks outlined above to this consent form, associated with in person and virtual physiotherapy services provided by the Registered Physiotherapist.

CANCELLATION & NO-SHOW POLICY

HigherGround strives to provide exceptional care to our clients. We aim to provide care that best meets your needs and schedules. However, missed clinic appointments and frequent cancellations do impact our ability to provide quality services.

In order to respect the time of our clinicians and to offer fair availability to all of our patients, we kindly ask for 24 hours notice to cancel a clinic appointment.  In the absence of 24 hours notice or in the case of a no-show, the full fee for the scheduled service will be applied to your account. This fee must be paid in full before or at the time of your next appointment. We are not able to bill insurance plans for missed or no-show appointments.

LATE PATIENT POLICY

At HigherGround, our goal is to make every clinic visit efficient, enjoyable, and stress-free. Late clients impact the quality of care by reducing patient time with the clinician. If you are late, we will make every effort to see you for the remainder of the scheduled time. The full fee for the scheduled service will be charged for this appointment.

By signing below, you accept the terms of our cancellation, no show, and late patient policies and agree to pay any charges to your account that may result.

By signing this Digital Signature a capture of your IP address and location will be submitted to HigherGround confirming your consent.

• We are able to bill some (not all) insurance companies directly for your Physiotherapy, Massage Therapy, Chiropractic and Acupuncture treatments.
• As the policy holder, it is your responsibility to contact your insurance company and confirm the exact details of your coverage including requirement for physician requisitions. Our front desk staff would be happy to assist you with any questions regarding your insurance coverage for our services.
• You may be required to pay a deductible or make a co-payment if your insurance plan defines so. Deductibles & co-payments are due at the end of your visit. Any unpaid balances will be charged to your credit card on file.
• We are only able to direct bill to your primary insurance plan. We are not able to do any co-ordination of benefits to secondary plans (spouse or other parent's plans).
• If you have been involved in a motor vehicle accident & have extended health insurance, your auto insurer requires your treatments to be billed to the extended health plan first. Please provide primary & secondary (if applicable) insurance information below: