Consent to Treat

I, (the "Patient") acknowledge that as a new patient of Cardio-Go's Health Centre at the King West Club (the "Club"). The Patient has read the information included herein, and understands that the form of medical care is based on holistic and natural methods of healing. The Patient recognizes that even the gentlest therapies potentially have complications in certain physiological conditions or in very young children or those on multiple medications and hence the information provided herein is complete and inclusive of all health concerns including risk of pregnancy; and all medications, including over the counter drugs and supplements.

The Patient hereby requests and consents to the performance of the services of the practitioner (the "Practitioner") provided at the Club for the purpose of assessing and treating my condition(s), which may without limiting the generality of the following include: acupuncture, Traditional Chinese Medicine, nutritional counseling, lifestyle counseling, herbal medicine, massage therapy, hot stone therapy, laser therapy, aromatherapy, reflexology, and reiki individually and collectively (the "Treatments"). The Patient understands that there may be slight risks of some Treatments which can include, but are not limited to: aggravation of pre-existing symptoms; allergic reaction to supplements or herbs; pain, fainting, bruising or injury from acupuncture; discomfort from laser therapy; and/or muscle tenderness, stiffness, or slight bruising from massage.

The Patient has had the opportunity to discuss with the Practitioner the nature of the care and Treatments. The Patient does not expect the Practitioner to be able to anticipate and explain all the risks and complications associated with the Treatments. The Patient agrees to rely on the Practitioner exercising judgment during the course of my Treatments, to apply those Treatments which the Practitioner feels at the time are in my best interest. The Patient understands that results of the Treatments are not guaranteed.

The Patient understands that the Practitioner will keep a record of the health care and Treatments provided to me. This record will be kept confidential and will not be released to others without the Patient's prior written consent, unless required by law. The Patient may look at and request a copy of the medical record at any time.

The Patient has read the above information and have had the opportunity to ask questions about its content. The Patient has the right, in its sole discretion, to withdraw this consent and to discontinue Treatments at any time. The Patient confirms that it has the unfettered ability and right to accept or reject these Treatments. The Patient is not an agent of any private, local, county, provincial or federal agency attempting to gather information without first so stating. The Patient accepts full responsibility for any and all costs and fees incurred during care and Treatments. The Patient intends that this consent form to cover the entire course of care and Treatments for my present condition and for any future condition(s) for which I seek care and Treatments at the Club.

Cancellation Policy:

If the Patient is unable to make a scheduled appointment, the Club will be promptly notified by phone at least 24 hours before the scheduled appointment. The Patient accepts that a $50.00 charge will be applied to the Patient's account for any missed appointment, or failure to notify of cancellation not less than 24 hours prior to the scheduled appointment.

WAIVER AND RELEASE

The Patient agrees to abide with and keep and obey all rules and regulations now in force or in the future prescribed by The King West Club during the course of the assessment and Treatments to be perfomed by the Practitioner at Cardio-Go's Health Centre at the King West Club (the "Club").

The Patient expressly states hereby that he/she will be voluntarily receiving the assessment and Treatments referred to in the Patient’s Intake form and the Informed Consent to which this waiver and release is attached and the Patient hereby assumes all risks of injury or every nature whatsoever with might result from the receipt of such assessment and Treatments at the Club. The Patient hereby waives and releases any and all claims that he/she has or may have against the Club, its employees or agents for injury sustained by the Patient as a result of the receipt of the assessment and Treatments to be performed by the Practitioner. The Patient hereby acknowledges that he/she has carefully read this waiver and release and fully understands that it is a waiver and release of liability of the Club and agrees that such a waiver and release is reasonable and proper based on the nature of the Club’s business.

The Patient hereby waives and releases the Club from any claims of every nature or kind whatsoever that he/she may have against the Club with respect to any loss or theft of personal property in respect of the facilities operated by the Club.

Privacy of personal information is an important principle at Cardio-Go. We are committed to collecting, using and disclosing personal information responsibly and only to the extent necessary for the good and services we provide. We also try to be as open and transparent as to how we handle personal information.
If you have any questions, please ask the Front Desk staff or the Health Care Practitioners.

• 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: