AUTHORIZATION FOR RELEASE OF CLIENT INFORMATION
Patient Name: {{ $data['authorization-pdf-form']->patient_name }}
Date Of Birth: {{ $data['authorization-pdf-form']->dob }}

PART A - Pertaining to Extended Health Care Centre

I, the undersigned, hereby authorize representatives of Alliston Physiotherapy and Sports Rehabilitation to be permitted to review related records, progress reports and to discuss pertinent data with professionals involved in my rehabilitation process.

Collection, use, disclosure, security and retention of information is subject to and in compliance with the Personal Information Protection and Electronic Documents Act (please see a copy of our privacy policy) I agree that a photocopy of this authorization be accepted if necessary
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Date: {{ $data['authorization-pdf-form']->partA_date1 }}
Date: {{ $data['authorization-pdf-form']->partA_date2 }}

PART B - Pertaining to Clients with Work Related and/or Motor Vehicle Injuries

I hereby authorize Alliston Physiotherapy and Sports Rehabilitation to release pertinent functional and medical information to my Doctor(s), Representatives of the Workplace Safety & Insurance Board / Representatives of Insurance Provider / Lawyer or Representatives / other Health Care Providers. In regards to Workplace Safety & Insurance Board claims, the undersigned hereby consents & authorize you to provide to my employer, periodic progress reports in the course of my treatment at Alliston Physiotherapy & Sports Rehabilitation. If required to provide progress reports, you are authorized to make reference to information that you may have in your possession which relates to my treatment. Collection, use, disclosure, security and retention of information is subject to and in compliance with the Personal Information Protection and Electronic Documents Act (please see a copy of our privacy policy) I agree that a photocopy of this authorization be accepted if necessary.
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Date: {{ $data['authorization-pdf-form']->partB_date1 }}
Date: {{ $data['authorization-pdf-form']->partB_date2 }}
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ALLISTON PHYSIOTHERAPY & SPORTS REHABILITATION
Patient Name: {{ $data['health-questionnaire-pdf-form']->patient_name }}
Date {{ $data['health-questionnaire-pdf-form']->date }}
Family Doctor's Name {{ $data['health-questionnaire-pdf-form']->doctor_name }}
Doctors Phone No {{ $data['health-questionnaire-pdf-form']->doctor_phone }}
Do you have any heart problems? {{ $data['health-questionnaire-pdf-form']->has_heart_problems == 1 ? 'Yes' : 'No' }}
Heart problems? {{ $data['health-questionnaire-pdf-form']->heart_problems }}
Heart problems files? {{ $data['health-questionnaire-pdf-form']->heart_problems_file }}
Do you have any thyroid problems? {{ $data['health-questionnaire-pdf-form']->has_thyroid_problems == 1 ? 'Yes' : 'No' }}
Thyroid problems? {{ $data['health-questionnaire-pdf-form']->thyroid_problems }}
Do you have HIGH or LOW blood pressure? {{ $data['health-questionnaire-pdf-form']->has_blood_pressure == 1 ? 'Yes' : 'No' }}
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Are you currently taking any medications? {{ $data['health-questionnaire-pdf-form']->taking_medications == 1 ? 'Yes' : 'No' }}
If yes, please list {{ $data['health-questionnaire-pdf-form']->medication_list }}
If yes, please list {{ $data['health-questionnaire-pdf-form']->medication_image }}
Have you been diagnosed with arthritis? {{ $data['health-questionnaire-pdf-form']->has_arthritis == 1 ? 'Yes' : 'No' }}
Diagnosed with arthritis? {{ $data['health-questionnaire-pdf-form']->diagnosed_with_arthritis }}
Do you have diabetes? {{ $data['health-questionnaire-pdf-form']->has_diabetes == 1 ? 'Yes' : 'No' }}
Diabetes? {{ $data['health-questionnaire-pdf-form']->diabetes }}
Do you have or ever had cancer? {{ $data['health-questionnaire-pdf-form']->cancer == 1 ? 'Yes' : 'No' }}
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Have you ever broken a bone? {{ $data['health-questionnaire-pdf-form']->has_broken_bone == 1 ? 'Yes' : 'No' }}
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Do you have any metal fixations, plates, screws, etc.? {{ $data['health-questionnaire-pdf-form']->has_metal_fixations == 1 ? 'Yes' : 'No' }}
Any metal fixations, plates, screws, etc.? {{ $data['health-questionnaire-pdf-form']->metal_fixations }}
Do you smoke? {{ $data['health-questionnaire-pdf-form']->do_you_smoke == 1 ? 'Yes' : 'No' }}
How much {{ $data['health-questionnaire-pdf-form']->smoke_much }}
Do you have any abdominal problems, ie hernia, ulcer? {{ $data['health-questionnaire-pdf-form']->has_abdominal_problems == 1 ? 'Yes' : 'No' }}
Any abdominal problems, ie hernia, ulcer? {{ $data['health-questionnaire-pdf-form']->abdominal_problems }}
Have you had any previous surgeries {{ $data['health-questionnaire-pdf-form']->has_previous_surgeries == 1 ? 'Yes' : 'No' }}
Previous surgeries list {{ $data['health-questionnaire-pdf-form']->previous_surgeries_list }}
If female, are you or could you be pregnant? {{ $data['health-questionnaire-pdf-form']->is_pregnant == 1 ? 'Yes' : 'No' }}
Could you be pregnant? {{ $data['health-questionnaire-pdf-form']->pregnant }}
Have you been involved in a previous car accident? {{ $data['health-questionnaire-pdf-form']->has_car_accident == 1 ? 'Yes' : 'No' }}
Accident Date {{ $data['health-questionnaire-pdf-form']->car_accident_date }}
Do you have any allergies, skin irritations, infections, etc? {{ $data['health-questionnaire-pdf-form']->has_allergies == 1 ? 'Yes' : 'No' }}
Any allergies, skin irritations, infections, etc? {{ $data['health-questionnaire-pdf-form']->any_allergies }}
Do you have asthma or any respiratory problems? {{ $data['health-questionnaire-pdf-form']->asthma == 1 ? 'Yes' : 'No' }}
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Do you have any other health problems not listed above? {{ $data['health-questionnaire-pdf-form']->has_other_health_problems == 1 ? 'Yes' : 'No' }}
Any other health problems not listed above? {{ $data['health-questionnaire-pdf-form']->other_health_problems }}
Is there any other reason that you should not do physical activities? {{ $data['health-questionnaire-pdf-form']->has_other_reason == 1 ? 'Yes' : 'No' }}
Any other reason that you should not do physical activities? {{ $data['health-questionnaire-pdf-form']->any_other_reason }}
When was your last Physiotherapy visit {{ $data['health-questionnaire-pdf-form']->last_physiotherapy_visit }}
Where was your last Physiotherapy visit {{ $data['health-questionnaire-pdf-form']->last_physiotherapy_location }}
Emergency contact person {{ $data['health-questionnaire-pdf-form']->emergency_contact_person }}
Emergency Phone {{ $data['health-questionnaire-pdf-form']->emergency_phone }}
Client’s Signature {{ $data['health-questionnaire-pdf-form']->client_signature }}
INFORMED CONSENT TO PHYSIOTHERAPY TREATMENT
I hereby request and consent to the performance of physiotherapy treatments and other physiotherapy procedures and techniques, including various modes of physical modalities, manual techniques and exercise on me by the physiotherapist. Physiotherapy assistants/kinesiologist will be part of providing treatment and will work under physiotherapist supervision named below or any provider covering for the treating physiotherapist working in this clinic authorized by the physiotherapist.
I have had the opportunity to discuss with the physiotherapist named below the nature and purpose of physiotherapy treatment and other procedures. I understand that results are not guaranteed and only the treating physiotherapist will be responsible for any issues related or arising from treatment not the clinic, as all health care practices, there are some slight risks of injury with treatment including, but not limited to, soft tissue sprains/ strains, pain, heart attacks, stroke, etc. and agree to keep the therapist informed of any changes in my condition (sometimes patients get bruising from soft tissue that’s normal). Also, I had the opportunity to discuss the payment plan with the office administration regarding my private insurance, WSIB and MVA before IA.

FEE STRUCTURE FOR WSIB AND MVA:
ALL WSIB AND MVA PAYMENTS WILL BE CHARGED AS PER THE STANDARD FEE GUIDE.FOR MVA WILL GO THROUGH YOUR EXTENDED HEALTH INSURANCE FIRST.PER SESSION COST IS $99.75 AND INITIAL ASSESSMENT IS $215 FOR MVA.
PRIVATE INSURANCE FEE STRUCTURE:
INITIAL ASSESMENT FOR ONE PART: $ 115
FOLLOWS UP SESSIONS: $75
INITIAL ASSESMENT FOR MULTI PARTS: $140
FOLLOWS UP SESSIONS: $100
INITIAL FOR TMJ: $130
FOLLOWS UP: $100
INITIAL FOR VESTIBULAR: $130 		FOLLOWS UP: $100 INITIAL FOR VESTIBULAR: $130
FOLLOW UP: $100
LASER THERAPY: $100 PER SESSION
SHOCKWAVE: $120 PER SESSION
ACCUPUNTURE $100 TRACTION: $100 PER SESSION
INITIAL ASSESSMENT CONCUSSION: $130
FOLLOWS UP SESSIONS: $100
CONSENT TO PAYMENT
I understand that I am responsible for payment of any fee for each treatment unless this is paid for by my motor vehicle insurer or the Work Place Safety and Insurance Board.
I understand that I am responsible for keeping scheduled appointments and that I will be charged a full treatment charge for appointments missed including WSIB/MVA without prior cancellation by phone or in person. All overdue and outstanding payments will be charged with an additional 5% interest after 30 days and any pending accounts after 30 days will be transferred to our accounts department.
Physiotherapist’s Name {{ $data['informed-consent-physiotherapy-treatment-pdf-form']->physiotherapists_name }}
Physiotherapist’s Signature {{ $data['informed-consent-physiotherapy-treatment-pdf-form']->physiotherapists_signature }}
Patient Name {{ $data['informed-consent-physiotherapy-treatment-pdf-form']->patient_name }}
Patient Signature {{ $data['informed-consent-physiotherapy-treatment-pdf-form']->patient_signature }}
Witness Signature {{ $data['informed-consent-physiotherapy-treatment-pdf-form']->witness_signature }}
Date {{ $data['informed-consent-physiotherapy-treatment-pdf-form']->date }}
Respectful Conduct Policy
PART A - Pertaining to Extended Health Care Centre
At Alliston Physiotherapy and Sports Rehabilitation, we are committed to providing a safe, respectful, and supportive environment for both our clients and staff. Abusive language, aggressive behavior, or any form of misconduct toward our staff will not be tolerated.
We appreciate your cooperation in maintaining a positive and professional atmosphere for everyone.

— Management Of Alliston Physiotherapy and Sports Rehabilitation
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Date Of Birth {{ $data['respectful-conduct-policy-pdf-form']->date }}
OFFICE USE ONLY- INSURANCE INFORMATION
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Member Name {{ $data['respectful-conduct-policy-pdf-form']->member_name }}
Policy Number {{ $data['respectful-conduct-policy-pdf-form']->policy_number }}
ID Number {{ $data['respectful-conduct-policy-pdf-form']->id_number }}
Total Max for Physio {{ $data['respectful-conduct-policy-pdf-form']->total_max_for_physio }}
Percentage {{ $data['respectful-conduct-policy-pdf-form']->physio_percentage }}
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Percentage {{ $data['respectful-conduct-policy-pdf-form']->massage_percentage }}
Total max Of Braces {{ $data['respectful-conduct-policy-pdf-form']->total_max_for_braces }}
Percentage {{ $data['respectful-conduct-policy-pdf-form']->braces_percentage }}
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CONSENT FOR SOFT TISSUE RELEASE
Please read this information carefully, and ask your practitioner if there is anything you do not understand

What is soft tissue release?
Soft tissue release focuses on the outer layers of muscle fibres, aiming for relaxation and relief from minor muscle tensions. It is a gentler approach, employing techniques like kneading, stroking, and tapping to enhance blood circulation and promote a state of well- being.

What are the benefits of soft tissue release?
Soft tissue release techniques can significantly enhance flexibility, allowing for greater movement and improved performance in both athletic and daily activities. By releasing tension and restoring proper tissue function, STR enables individuals to move more freely and efficiently.

What is the purpose of soft tissue release?
Muscle soft tissue therapy, is used extensively to reduce thickened or tight connective tissue, to release myofascial trigger points that inhibit muscle contraction or cause pain and are used to reduce muscle tone and tension.

What does soft tissue release do to your body?
Soft tissues connect and support other tissues and surround the organs in the body. They include muscles (including the heart), fat, blood vessels, nerves, tendons, and tissues that surround the bones and joints.

What are the side effects to soft tissue release?
1. Patients may experience mild to standard soreness.
2. Patients may have bruising after treatment that could last up to 2 weeks.
3. Patient may have temporary pain flares and fatigue.

Statement of consent:
I confirm that I have read and understand the above information, and I consent to having soft tissue release done as a part of my treatment. I understand that I can refuse treatment at any time.
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Date {{ $data['consent-soft-tissue-release-pdf-form']->date }}
Sports Rehabilitation
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Date Of Birth {{ $data['sports-rehabilitation-pdf-form']->dob }}
Injured Area {{ $data['sports-rehabilitation-pdf-form']->injured_area }}
Assessment Date {{ $data['sports-rehabilitation-pdf-form']->assessment_date }}
Email {{ $data['sports-rehabilitation-pdf-form']->email }}
Address {{ $data['sports-rehabilitation-pdf-form']->address }}
Phone {{ $data['sports-rehabilitation-pdf-form']->phone }}
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If other {{ $data['sports-rehabilitation-pdf-form']->hear_about_other }}
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Call Us: 705-434-0645
Email: info@allistonphysiotherapy.ca 		Address: 27 Victoria Street E, Alliston,
ON L9R 1T9, Canada
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