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Thank you for choosing One Wellness for your therapy needs.
Please take a moment to provide us with some basic personal information.

One Wellness does not disclose any personal information to third parties without the prior consent of the client. 

Date: August 4, 2020

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First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Age:

Alberta Health Care Number: *

Occupation:

Employer:

Please indicate (with an 'x') if any of the following apply:

Arthritis (Any Form)
Blood Pressure
Bruise Easily
Diabetes
Epilepsy
Head/Neck Trauma
Heart Issues
Illness (Ex. Cancer)
Kidney Disease
Lung Issues
Major Operations
Numbness/Tingling/Hypersensitivity (where?)
Pacemaker
Pregnant
Respiratory Issues
Skin Conditions/Lesions/Plantar Warts/Infections
Thyroid

Other (please specify)

Allergies? Please identify

Please list your current medications

Area of concern (injury):

Name of Health Care Providers involved in your care:


Family Physician: *

Other Physicians/Surgeons:

Other Health Professionals:
Do you give One Wellness consent to discuss your care with the above professionals?*

In Case of Emergency:


Name of close friend or relative: *

Relationship to you: *

Phone Number: *

How did you hear about One Wellness?

Click to customize pull down*

If you were referred by a friend, please let us know their full name so we can thank them.

IF YOU WOULD LIKE US TO DIRECT BILL FOR YOU PLEASE FILL OUT THE FOLLOWING ASSIGNMENT OF BENEFITS:

Assignment of Benefits

I request that payment under my medical insurance program be made to ONE WELLNESS for any services or equipment furnished to me.  I authorize ONE WELLNESS to release any information needed for this claim to the necessary carriers or their intermediates.  I also request that a copy of this authorization be used in place of the original.

Statement of Confidentiality

I authorize the release of necessary medical information to ONE WELLNESS for the purposes of processing this or any related insurance claims.  I also give ONE WELLNESS the authority to make available any requested documents contained in my file to myself and/or other health care providers involved in the treatment of my condition.

Agreement

I acknowledge that I am fully responsible for the payment of any services and equipment provided to me by ONE WELLNESS.  I understand that if ONE WELLNESS submits a claim for billed charges to my health plan(s) on my behalf, I am not relieved of my financial responsibility for payment.  In the event that the health plan or any third party payer does not pay the entire billed amount, I agree to pay any remaining balance.

By signing below, I acknowledge and accept the terms and conditions stated above.


Primary Card Holder:

Primary Card Holders DOB:

Insurance Company:

ID Number:

Group/Policy Number:

Secondary Insurance


Primary Cardholder

Primary Cardholder's DOB

Insurance Company

ID Number

Group/Policy Number

I understand that I am personally responsible for all treatment costs

We kindly request 24 hours' notice if an appointment needs to be rescheduled as we often have others on our waitlist. A cancellation penalty of the full cost of the appointment will be implemented for insufficient notice. 

Informed Consent for Patients receiving Physiotherapy Treatment

Joint Manipulations: A manipulation is a high velocity, low amplitude thrust on a bone to allow motion of a joint. It is a safe and effective method to reinstate motion in a joint and reduce the pain in your muscles the surrounding area. There is often a "pop" or "click" that may occur; this is simply air pressure releasing. Your physiotherapist will test your joint prior to the manipulation as he/she explains to process to you. They will also retest the joint after the manipulation to ensure that target results were achieved. Manipulations will not be performed on individuals with deficient bone, ligament laxity, collagen disorders or when consent is not given. 

Acupuncture and Intermuscular Stimulation (IMS) : This is a technique that your physiotherapist may perform to decrease pain and restore normal functionality of your muscles. It consists of inserting acupuncture needles into a muscle. Before performing this technique, your physiotherapist will ensure that you are a good candidate for this technique. 

Please sign below to acknowledge your consent to treatment and your understanding of the liability of any costs incurred by you at this office. 

I understand that is my right to be a partner in my treatment program and that is my responsibility to inform the therapist of any discomfort that I may experience during the course of treatment. I understand that the therapist will only provide treatments that the therapist is qualified to provide and that it is the responsibility of the therapist to inform me of any risks that may or may not be associated with the treatments that I receive; including but not limited to Acupuncture, Joint Mobilization and Manipulations, Intramuscular Stimulation and Soft Tissue Therapy. I know that I have the right to reuse any treatments and or techniques recommended by the therapist. 

I consent to the physiotherapy treatments offered or recommended to me by my physiotherapist and intend to consent to apply to all my present and future physiotherapy care. 

Consent for electronic communication and/or the provision of services through email, text, social media, and video-rehabilitation/ videoconferencing.

I am aware of the following:

1.  Risks of using electronic communication

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

· Use of electronic communications to discuss sensitive information can increase the risk of such information being disclosed to third parties.

· Despite reasonable efforts to protect the privacy and security of electronic communication, itis not possible to completely secure the information.

· Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system.

· 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 Service Provider that may prevent the Service Provider from being able to provide services

· Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the Service Provider or the patient.

· Even after the sender and recipient have deleted copies of electronic communications, back-up copies may exist on a computer system.

· Electronic communications may be disclosed in accordance with a duty to report or a court order. · Videoconferencing using no cost, publicly available services may be more open to interception than other forms of videoconferencing

· There may be limitations in the services that can be provided through electronic communications, dependent on the means of electronic communications being utilized

· Email, text messages, and instant messages can more easily be misdirected, resulting in increased risk of being received by unintended and unknown recipients.

· Email, text messages, and instant messages can be easier to falsify than handwritten or signed hard copies. It is not feasible to verify the true identity of the sender, or to ensure that only the recipient can read the message once it has been sent.

2.  Conditions of Using Electronic Communications:

· While the Service Provider will endeavour to review electronic communications in a timely manner, the Service Provider cannot provide a timeline as to when communications will be reviewed and responded to. Electronic communications will not and should not be used for medical emergencies or other time-sensitive matters.

· Electronic communication may not be an appropriate substitute for some services that the Service Provider offers.

· Electronic communications may be copied or recorded in full or in part and made part of your clinical chart. Other individuals authorized to access your clinical chart, such as staff and billing personnel, may have access to those communications.

· The Service Provider may forward electronic communications to staff and those involved in the delivery and administration of your care. The Service Provider will not forward electronic communications to third parties, including family members, without your prior written consent, except as authorized or required by law.

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

o Steps to be followed in the event of a technical issue that causes a disruption in the services that are being provided by the Service Provider; and

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

· The Service Provider is not responsible for information loss due to technical failures associated with your software or internet service provider.

· The Patient will inform the Service Provider of any changes in the patient's email address, mobile phone number, or other account information necessary to communicate electronically.

· The Patient will ensure the Service Provider is aware when they receive an electronic communication from the Service Provider, such as by a reply message or allowing "read receipts" to be sent.

· The Patient will take precautions to preserve the confidentiality of electronic communications, such as using screen savers and safeguarding computer passwords.

· If the Patient no longer consents to the use of electronic communications by the Service Provider, then the Patient will provide notice of the withdrawal of consent by email or other written communication.

Acknowledgement and Agreement

I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of the selected electronic communications as described above. I understand and accept the risks outlined above to this consent form, associated with the use of the electronic communications with the Service Provider and the Service Provider's staff. I consent to the conditions and will follow the instructions outlined above, as well as any other conditions that the Service Provider may impose regarding electronic communications with patients. I acknowledge and agree to communicate with the Service Provider or the Service Provider's staff using these electronic communications with a full understanding of the risks in doing so. I confirm that any questions that I had regarding the provision of services through electronic communications have been answered.

First Client's Signature*
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Age:

Alberta Health Care Number: *

Occupation:

Employer:

Please indicate (with an 'x') if any of the following apply:

Arthritis (Any Form)
Blood Pressure
Bruise Easily
Diabetes
Epilepsy
Head/Neck Trauma
Heart Issues
Illness (Ex. Cancer)
Kidney Disease
Lung Issues
Major Operations
Numbness/Tingling/Hypersensitivity (where?)
Pacemaker
Pregnant
Respiratory Issues
Skin Conditions/Lesions/Plantar Warts/Infections
Thyroid

Other (please specify)

Allergies? Please identify

Please list your current medications

Area of concern (injury):

Name of Health Care Providers involved in your care:


Family Physician: *

Other Physicians/Surgeons:

Other Health Professionals:
Do you give One Wellness consent to discuss your care with the above professionals?*

In Case of Emergency:


Name of close friend or relative: *

Relationship to you: *

Phone Number: *

How did you hear about One Wellness?

Click to customize pull down*

If you were referred by a friend, please let us know their full name so we can thank them.

IF YOU WOULD LIKE US TO DIRECT BILL FOR YOU PLEASE FILL OUT THE FOLLOWING ASSIGNMENT OF BENEFITS:

Assignment of Benefits

I request that payment under my medical insurance program be made to ONE WELLNESS for any services or equipment furnished to me.  I authorize ONE WELLNESS to release any information needed for this claim to the necessary carriers or their intermediates.  I also request that a copy of this authorization be used in place of the original.

Statement of Confidentiality

I authorize the release of necessary medical information to ONE WELLNESS for the purposes of processing this or any related insurance claims.  I also give ONE WELLNESS the authority to make available any requested documents contained in my file to myself and/or other health care providers involved in the treatment of my condition.

Agreement

I acknowledge that I am fully responsible for the payment of any services and equipment provided to me by ONE WELLNESS.  I understand that if ONE WELLNESS submits a claim for billed charges to my health plan(s) on my behalf, I am not relieved of my financial responsibility for payment.  In the event that the health plan or any third party payer does not pay the entire billed amount, I agree to pay any remaining balance.

By signing below, I acknowledge and accept the terms and conditions stated above.


Primary Card Holder:

Primary Card Holders DOB:

Insurance Company:

ID Number:

Group/Policy Number:

Secondary Insurance


Primary Cardholder

Primary Cardholder's DOB

Insurance Company

ID Number

Group/Policy Number

I understand that I am personally responsible for all treatment costs

We kindly request 24 hours' notice if an appointment needs to be rescheduled as we often have others on our waitlist. A cancellation penalty of the full cost of the appointment will be implemented for insufficient notice. 

Informed Consent for Patients receiving Physiotherapy Treatment

Joint Manipulations: A manipulation is a high velocity, low amplitude thrust on a bone to allow motion of a joint. It is a safe and effective method to reinstate motion in a joint and reduce the pain in your muscles the surrounding area. There is often a "pop" or "click" that may occur; this is simply air pressure releasing. Your physiotherapist will test your joint prior to the manipulation as he/she explains to process to you. They will also retest the joint after the manipulation to ensure that target results were achieved. Manipulations will not be performed on individuals with deficient bone, ligament laxity, collagen disorders or when consent is not given. 

Acupuncture and Intermuscular Stimulation (IMS) : This is a technique that your physiotherapist may perform to decrease pain and restore normal functionality of your muscles. It consists of inserting acupuncture needles into a muscle. Before performing this technique, your physiotherapist will ensure that you are a good candidate for this technique. 

Please sign below to acknowledge your consent to treatment and your understanding of the liability of any costs incurred by you at this office. 

I understand that is my right to be a partner in my treatment program and that is my responsibility to inform the therapist of any discomfort that I may experience during the course of treatment. I understand that the therapist will only provide treatments that the therapist is qualified to provide and that it is the responsibility of the therapist to inform me of any risks that may or may not be associated with the treatments that I receive; including but not limited to Acupuncture, Joint Mobilization and Manipulations, Intramuscular Stimulation and Soft Tissue Therapy. I know that I have the right to reuse any treatments and or techniques recommended by the therapist. 

I consent to the physiotherapy treatments offered or recommended to me by my physiotherapist and intend to consent to apply to all my present and future physiotherapy care. 

Consent for electronic communication and/or the provision of services through email, text, social media, and video-rehabilitation/ videoconferencing.

I am aware of the following:

1.  Risks of using electronic communication

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

· Use of electronic communications to discuss sensitive information can increase the risk of such information being disclosed to third parties.

· Despite reasonable efforts to protect the privacy and security of electronic communication, itis not possible to completely secure the information.

· Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system.

· 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 Service Provider that may prevent the Service Provider from being able to provide services

· Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the Service Provider or the patient.

· Even after the sender and recipient have deleted copies of electronic communications, back-up copies may exist on a computer system.

· Electronic communications may be disclosed in accordance with a duty to report or a court order. · Videoconferencing using no cost, publicly available services may be more open to interception than other forms of videoconferencing

· There may be limitations in the services that can be provided through electronic communications, dependent on the means of electronic communications being utilized

· Email, text messages, and instant messages can more easily be misdirected, resulting in increased risk of being received by unintended and unknown recipients.

· Email, text messages, and instant messages can be easier to falsify than handwritten or signed hard copies. It is not feasible to verify the true identity of the sender, or to ensure that only the recipient can read the message once it has been sent.

2.  Conditions of Using Electronic Communications:

· While the Service Provider will endeavour to review electronic communications in a timely manner, the Service Provider cannot provide a timeline as to when communications will be reviewed and responded to. Electronic communications will not and should not be used for medical emergencies or other time-sensitive matters.

· Electronic communication may not be an appropriate substitute for some services that the Service Provider offers.

· Electronic communications may be copied or recorded in full or in part and made part of your clinical chart. Other individuals authorized to access your clinical chart, such as staff and billing personnel, may have access to those communications.

· The Service Provider may forward electronic communications to staff and those involved in the delivery and administration of your care. The Service Provider will not forward electronic communications to third parties, including family members, without your prior written consent, except as authorized or required by law.

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

o Steps to be followed in the event of a technical issue that causes a disruption in the services that are being provided by the Service Provider; and

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

· The Service Provider is not responsible for information loss due to technical failures associated with your software or internet service provider.

· The Patient will inform the Service Provider of any changes in the patient's email address, mobile phone number, or other account information necessary to communicate electronically.

· The Patient will ensure the Service Provider is aware when they receive an electronic communication from the Service Provider, such as by a reply message or allowing "read receipts" to be sent.

· The Patient will take precautions to preserve the confidentiality of electronic communications, such as using screen savers and safeguarding computer passwords.

· If the Patient no longer consents to the use of electronic communications by the Service Provider, then the Patient will provide notice of the withdrawal of consent by email or other written communication.

Acknowledgement and Agreement

I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of the selected electronic communications as described above. I understand and accept the risks outlined above to this consent form, associated with the use of the electronic communications with the Service Provider and the Service Provider's staff. I consent to the conditions and will follow the instructions outlined above, as well as any other conditions that the Service Provider may impose regarding electronic communications with patients. I acknowledge and agree to communicate with the Service Provider or the Service Provider's staff using these electronic communications with a full understanding of the risks in doing so. I confirm that any questions that I had regarding the provision of services through electronic communications have been answered.

Parent or Guardian's Signature*
Electronic Signature Consent to Treatment*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.<br><br> The undersigned agrees to indemnify and hold harmless One Wellness, its officers and directors, employees, contractors, and its affiliates and their respective successors and assigns and each other person, if any, who controls any thereof, against any loss, liability, claim, damage and expense whatsoever (including, but not limited to, any and all expenses whatsoever reasonably incurred in investigating, preparing or defending against any litigation commenced or threatened or any claim whatsoever) arising out of or based upon any false representation or warranty or breach or failure by the undersigned to comply with any covenant or agreement made by the undersigned herein or in any other document furnished by the undersigned to any of the foregoing in connection with this transaction.<br><br> One Wellness is committed to diversity and to equal opportunity inclusion. One Wellness does not discriminate on the basis of race, creed, color, ethnicity, national origin, religion, sex, sexual orientation, gender identity and expression, height, weight, physical or mental ability, veteran status, military obligations, or marital status. This includes but it not limited to; change rooms, bathroom facilities, usage of the fitness center and treatment areas. This policy applies to all One Wellness employees, guests, members, clients, and contractors.


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