RAMAIAH MEMORIAL HOSPITAL

CENTRE FOR REHABILITATION

CONSENT FORM

Date : ………………………
Patient Name: ……………………………………………………………………………………….

Patient Registration No : ……………………………………………

Age: ………………………….. Sex: …………. Diagnosis: …………………………………………………

Address: ………………………………………………………………………………………………………

…………………………………………………………………………………………………………….......

Primary contact and phone no in case of medical emergency: ………………………………………………

Contact No: ……………………………………………………..

I __________________________________________ wish to give consent to undergo hydrotherapy

treatment at M S Ramaiah memorial Hospital, Center for Rehabilitation.

I give my consent towards the assessment and therapeutic interventions which will be done for me by the
therapist during the course of my therapy. I have been explained in my own language about my treatment
program. I have had the opportunity to discuss and clarify any concerns with my therapist. A check list for
hydrotherapy and a list of dos and don’ts have been provided to me along with a copy of this consent form. I
have been explained about the hydrotherapy packages. I agree to choose one of the following packages as
applicable.

 Single Session 1050/- Validity NA

 5 Sessions 4730/- Validity 30 days
 10 Sessions 8500/- validity 45 days

I am aware that the validity of the package and have been explained about the rules and regulations
including cancellation policy.

Patient’s Full Name ……………………………… Therapist’s Full Name: ……………………………

Patient’s Signature……………………………….. Therapist’s Signature ……………………………..

Note : For cancellation policy please see overleaf

Cancellation Policy

 Maximum of 2 cancellations / rescheduling allowed in a package.

 Cancellation have to be intimated to the therapist at least 24 hours in advance
 Cancellation on the same day will be considered only in case of unavoidable
circumstances
 Cancellation of appointment beyond scheduled time or no show by patient, the
session will be forfeited
 Any unused sessions beyond validity period will be forfeited
 No refund requests will be entertained, please choose your package as per your
requirements.