Informed Consent

Physiotherapy involves many different types of physical evaluation and treatment. As with all forms of medical interventions, there are benefits and risks involved with the therapeutic regime. The physical and psychological response to treatment varies and cannot always be predicted as every individual is different. There is no guarantee that the treatment will help the condition one is seeking treatment for and there is a risk that the treatment may cause some discomfort or aggravation of the existing condition.

1. I hereby consent to participate in assessments and treatments given by the physiotherapist and the support personal. I acknowledge that my treatment provider has fully explained to me the nature and purposes of the procedures, evaluation and course of treatment, including the possible risks and side effects of the proposed treatment.
2. The physiotherapist has informed me of expected benefits and possible complications or discomfort, which may result from skilled physiotherapy care. In addition, the physiotherapist has explained to me the risks of receiving no treatment.
3. I may experience an increase in my current level of pain or discomfort, or an aggravation of my existing injury or condition. This discomfort is usually temporary; if it does not subside in a reasonable time period, I agree to contact my physiotherapist.
4. I may experience an improvement in my symptoms and an increase in my ability to perform daily activities. I may experience increased strength, awareness, flexibility and endurance in my movements. I may experience decreased pain and discomfort. I should gain a greater knowledge about managing my condition and the resources available to me.
5. The physiotherapist has explained that there is no guarantee that the proposed course of treatment will improve my condition and that it is possible, although unlikely, that the course of treatment may cause additional pain or discomfort or aggravate my condition.
6. In order for physiotherapy treatment to be effective, I must follow the plan of care prescribed by the attending physiotherapist. I understand and agree to cooperate with and perform the physiotherapy program intended for me. If I have trouble with any part of my treatment program, I will discuss it with my therapist.
7. The term “informed consent” means that the potential risks, benefits, and alternatives of physiotherapy treatment have been explained to me. Vivacare Advanced Physiotherapy & Pain Clinic provides a wide range of physiotherapy services and I understand that I will receive information during the initial home visit /online consultation (as applicable) concerning the treatment and options available for my condition.
8. I have been given on opportunity to ask questions, and all my questions have been answered to my satisfaction. I confirm that I have read and fully understand this consent form. In the event of a change in my medical status, I understand that my treatment may be modified, stopped, or referred out to the proper practitioner.
9. I agree to be contacted by Vivacare Advanced Physiotherapy & Pain Clinic over phone and email. I do not have any objection to receiving emails, messages (SMS or any other mode) and calls from Vivacare Advanced Physiotherapy & Pain Clinic. This consent shall supersede any preferences set through Do Not Disturb (DND Register)/ National Customer Preference Register (NCPR).
10. After my treatment plan is completed, I hereby authorize Vivacare Advanced Physiotherapy & Pain Clinic to use and publish my testimonial that may contain my image, my content, and likeness. I agree and understand I shall neither be compensated for the content nor receive attribution for the content. I also attest that I am authorized to grant the right to use this content. I understand that this content may be used in publications, press releases, marketing materials, advertisements (both digital and print), websites (including social media sites), or other uses. This authorization is continuous, and only I may withdraw this authorization through specific, written rescission.
11. I acknowledge that I have read and fully agree by the clinic’s Privacy Policy, which explains how my protected health information will be handled in various situations as permitted by law. I understand that I may discuss my concerns and or any questions I have concerning this Privacy Policy with the representatives of Vivacare Advanced Physiotherapy & Pain Clinic.
12. I am aware that Vivacare Advanced Physiotherapy & Pain Clinic does not accept health insurance and is a private-pay clinic. I agree to pay for the services rendered with cash, credit card, debit card, or UPI. I understand that I am liable to pay

• For treatment charges and the costs of materials (tapes, braces etc)
• A non-attendance fee of ₹200, if I cancel a scheduled appointment without notifying the clinic at least 4 hours in advance of a scheduled appointment.

Specific Consent for Telehealth

1. I consent to participating in a telehealth visit with a Physiotherapist, who is associated with Vivacare Advanced Physiotherapy & Pain Clinic. I understand that the evaluation and treatment of current medical condition(s) using a synchronous video and/or audio call is under the Physiotherapy scope of practice similar to a clinic visit and will be carried out by a licensed practitioner.
2. I understand that the telehealth session will use Zoom, a computer application that allows for encrypted video meetings. Encrypted meetings are private meetings between the Physiotherapist and the patient that keeps health information on a secure line, prevents hacking, and reduces invasion of privacy. I understand that Vivacare Advanced Physiotherapy & Pain Clinic may record the session for internal quality & training purposes. 
3. I understand the Physiotherapist will conduct the session in a space that is conducive for keeping health information private and maintain professional guidelines. I understand that no physical exam or manual therapy will be given during a telehealth visit and I agree to the Therapist’s plan of care that may be modified for telehealth.
4. I understand that this telehealth visit must be paid in full before the start of care. The Physiotherapist has the right to refuse treatment if payment is not received.

My consent is voluntary and I intend this consent form to cover the entire course of current & future assessments/treatments, commencing on the date of my registration.