Patient Identification Label

INFORMED CONSENT FOR PHYSIOTHERAPY

Name: Age: Gender: □ M □ F □ Others

Yrs
Registration No. Interpreter Service: □ Yes □ No Consultant’s Name:
MEDICAL CONDITION (to be filled by the patient or the Therapist to document in patient’s own words)
The Therapist has explained that I have the following medical condition: ………………………………………………………………………………
………………………………………………………………………………………………………………………………………. and I have been explained and
advised to undergo the following treatment/ procedure………......................................................................................................
…………………………………………………………………………………………………………………………………………………………………………………………………
INTRODUCTION
 It is a rehabilitation method that helps patients gain or regain their physical activities that they lost or that they are
incapable of doing due to defects either from birth or resulting from injuries or disease. There are various methods of
treatments to help one to regain and/or improve his or her physical function.  For Eg:
 An individualized exercise prescription
 Manual therapy techniques such as mobilization, manipulation, soft tissue release and stretches.
 Treatments through modalities such as heat, ice, therapeutic taping, ultrasound, laser, TENS, interferential current,
shock wave and electric muscular stimulation.
BENEFITS ALTERNATIVES (to be documented by Physiotherapist)
 Pain reduction
 Improvement in mobility, strength, endurance, function and
quality of life.
 Others:

RISKS AND COMPLICATIONS PATIENT SPECIFIC RISKS

 Manual therapy: Joint and/or muscle soreness 1)
 Exercise therapy: Joint and/or muscle soreness
 Electrical modalities: Minor skin irritations such as redness or 2)
rash Therapeutic Taping: Minor skin irritations such as redness
3)
or rash
 During Internal examination: Spotting, Pain/discomfort, 4)
Emotional stress, skin reaction(lubrication)
 Others: 5)

SPECIFIC NOTES RELATED TO PROCEDURE (if required) PRECISE ACTION POINTS UNDERSTOOD BY THE
PATIENT/SUBSTITUTE DECISION MAKER (to be documented
by patient/substitute decision maker)
 Patient Identification Label
INFORMED CONSENT FOR PHYSIOTHERAPY

PATIENT’S AUTHORIZATION
 The therapist has explained my medical condition and proposed procedure. I understand the risks of the procedure
including the risks that are specific to me, and the likely outcomes.
 The therapist has explained other relevant treatment options and their associated risks.
 The therapist has explained any significant risks and problems specific to me, and the likely outcomes if complications
occur. I have been given the choice to take a second opinion.
 I was able to ask questions and raise concerns with the doctor the procedure and its risks, and my treatment options. My
questions and concerns have been discussed and answered to my satisfaction.
 I understand that no guarantee has been made that the procedure will improve the condition.
 It has been explained to me, that during the course of or subsequent to the Procedure, unforeseen conditions may be
revealed or encountered which may necessitate urgent medical attention or other procedures in addition to or different
from those contemplated. In such exigency, I further request and authorize the above named therapist or his designee to
perform such additional procedures as s/he or they consider necessary or desirable.
 I understand that I have the right to refuse treatment or withdraw consent at any time. I agree that any such
refusal/withdrawal shall be in writing and acknowledged by the Hospital. And I shall be solely responsible for the outcome
of such refusal.
 I declare that I have received and fully understood the information provided in this consent form, that I have been given
an opportunity to ask questions and raise concerns with the doctor about the procedure and its risks and my treatment
options. All my queries and concerns have been discussed and answered to my full satisfaction.

Patient Substitute Decision Maker Witness Interpreter

Name: Name: Name: Name:

Relationship: Relationship: Relationship: Translation given in:

Reason (pt is unable to give consent
because):

Signature: Signature: Signature: Signature:

Date: Date: Date: Date:

Time: Time: Time: Time:

DECLARATION BY THE THERAPIST
I have explained the patient‘s condition, the treatment and the risks, likely consequences if those risks occur and the significant
risks and problems specific to this patient. I have given the Patient/ Guardian an opportunity to ask questions about any of the
above matters and raise any other concerns, which I have answered as fully as possible. I am of the opinion that the Patient/
Substitute Decision Maker understood the above information.
Name & Signature of the Doctor: Date & Time: