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Biomechanical Assessment and Treatment
Classical Acupuncture
Ultrasound / TENS & EMS
Radial Shockwave Therapy
Laser Therapy
Gunn Intramuscular Stimulation
Graston Technique
Exercise and Strength Training
Sports Taping
Consent Forms
Contact
Menu
Home
About
Services
Biomechanical Assessment and Treatment
Classical Acupuncture
Ultrasound / TENS & EMS
Radial Shockwave Therapy
Laser Therapy
Gunn Intramuscular Stimulation
Graston Technique
Exercise and Strength Training
Sports Taping
Consent Forms
Contact
Consent Forms
Full Name
Date of Birth
Saskatchewan Health Number:
Address
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Postal Code
Home Phone
Work Phone
Cell Phone
Email
Date of Injury
Area Injured
Previous Physiotherapy
Family Physician
Referred By
Also send reports to (if needed)
Employer
Self Pay
Treatment is provided on a fee-for service basis. Rates for treatment are $130 for initial assessment and $80 for follow-up sessions, $85 for Dry needling and $90 for Acupuncture. Your appointment time has been specially reserved for you, should you be unable to keep your appointment a minimum of 24 hours notice is appreciated. Failure to give adequate notice may result in a charge for the time and/or full prepayment of your next booking which will be non-refundable. My signature below indicates my acceptance of these fees and acknowledgement that I will pay for the services provided by Flaman Physiotherapy.
Client Name
Date
DND/DVA/RCMP
This clinic is able to bill these agencies directly with pre-approval. My signature below acknowledges that I will reimburse Flaman Physiotherapy for any costs that are not covered by these agencies. This clinic will send appropriate reports only to the family/referring doctor and the funding agency unless otherwise directed by the client
Client Name
Claim#/Mil. SN#
Date
WCB
This clinic is able to bill this agency directly. My signature below acknowledges that I will reimburse Flaman Physiotherapy for any costs that are not covered by these agencies. This clinic will send appropriate reports only to the family/referring doctor and the funding agency unless otherwise directed by the client.
Client Name
Claim#
Date
SGI
This clinic is able to bill this agency directly. My signature below acknowledges that I will reimburse Flaman Physiotherapy for any costs that are not covered by these agencies. This clinic will send appropriate reports only to the family/referring doctor and the funding agency unless otherwise directed by the client.
Client Name
Claim#
Case Mgr.
Date
I hereby consent to a physiotherapy assessment and treatment to be performed by Jason Flaman, BScPT, Cert. Sport P.T., Dip. Manip. P.T., FCAMT, Sask. Lic. # 1378, Kurtis Klutz, BScPT Graston Technique Lic# 1382, Provider, and/or Raschelle Steppan, BScPT CAFCI Lic# 1769.
I understand that assessment may include a physiotherapy scan examination, biomechanical assessment, appropriate functional and strength assessment for the specific injury, education on the nature of the conditions noted during the aforementioned procedures and discussion of appropriate further treatments, as well as any other techniques or methods within the scope of practice of the above named physiotherapist that are deemed necessary for the presenting injury.
I understand that treatment may consist of massage, extremity and spinal joint mobilisation, extremity and spinal joint manipulation, exercise prescription, taping and bracing, acupuncture, dry needling, graston soft tissue release, ultrasound, electrical stimulation, laser, shockwave therapy, and any other techniques or methods within the scope of practice of the above named physiotherapist that are deemed necessary for the presenting injury.
I understand I have the right to ask for full explanations of the assessment techniques and treatment techniques being used and to refuse any technique I am not comfortable with.
I understand I have the right to request a third party be present in the room for all assessment and treatment procedures, if so desired.
I understand that, depending on the nature and area of the injury, I may be asked to wear clothing (i.e gown/shorts) that allows access to the injured area by the therapist.
I understand I have the right to refuse to comply with this request if I am not comfortable with it.
I understand that all information gathered by this clinic is confidential, but it will be shared with insuring agents, third party payers, and/or physicians and other health care providers upon request.
I further understand that at any time I may rescind this consent by giving written notice.
I have read the above consent, and I have had the opportunity to ask questions about its content. This consent will cover the physiotherapy assessment and entire course of treatment.
Client/Guardian Name
Date
Surgeries
Medications (all medications for all conditions you are being treated for)
Past Medical history (heart and lung issues, diseases such as diabetes, any other conditions you are aware of)
Past Injuries
Past Physiotherapy treatment (if possible, include type of treatment received and for which injury injury)
Send
Insurance Information & Forms
Dry Needling & Information Consent Form
Acupuncture Treatment Consent Form
Spinal Manipulation Consent Form
Graston Technique Consent Form
