Consent to Pedorthic Servicesand Patient Rights and Responsibilities
The relationship between yourself and your pedorthist is a special one and we take it very seriously. You will be requested to read the following at your first visit and to sign your name in the appropriate place if you consent to treatment of yourself at the pedorthic clinic of Sound Orthotics Inc. The full text is provided here for your review.
Consent to Pedorthic Treatment
I hereby authorize and consent Sound Orthotics Inc. to the biomechanical assessment, gait analysis, casting procedures, techniques and clinical photographs that the pedorthist in attendance deem necessary for my care.
I understand that prior to any diagnostic procedure, technique, or taking of any clinical photograph, I will be advised by the pedorthist responsible for the care, and that I may ask questions concerning the treatment. I also understand that custom foot orthotics work in conjunction with proper footwear and I agree to abide by any recommendations made with regard to specific shoe features in the pedorthic treatment plan. I further understand that I may revoke this consent before such treatment is provided.
I hereby authorize and consent Sound Orthotics Inc. to release to government agencies, insurance carriers, or others who are financially liable for the pedorthic care, all information needed to substantiate payment for such care, and permits others who are representatives thereof to examine and make copies of all records relating to such care and treatment. However, after disclosure has been made, it cannot be revoked retroactively to cover information prior to revocation.
I understand this consent will remain in force until I revoke it in writing.
I hereby state that I have read and understood this consent form, and that I have been given the opportunity to ask questions I might have, and that all my questions have been answered in a satisfactory manner.
Patient’s Name: ______________________________________________
For whom consent for treatment is granted
Patients have a right to and responsibility for:
- Understand these rights. If necessary we will supply assistance.
- Receive treatment without discrimination as to race, religion, sexual orientation, disability or source of payment.
- Receive considerate and respectful care in a clean and safe environment.
- Receive emergency care if needed.
- Be informed of the name and position of the persons rendering care and names and positions of administrative staff
- Receive complete information about their pedorthic diagnosis, treatment, and prognosis
- Receive all the information needed for them to give informed consent including possible risks and benefits
- Refuse treatment and be told of the possible consequences of refusing that treatment.
- After a full explanation, have a right to refuse to take part in research.
- Privacy and confidentiality of all information regarding your care.
- Participate in decisions regarding your care.
- Obtain your pedorthic record for which you may be charged a reasonable fee. You cannot be denied a copy solely because of inability to pay.
- Receive a receipt with an explanation of all charges.
- Complain without fear of reprisals. If you are not satisfied, you may address your concerns to the College of Pedorthics of Canada at (866) 819-4354.
Start Your Journey Toward Pain-Free Living Today!
Get in touch with us at 705-342-7728 or at email@example.com or come visit us at our 8 Murray Point Road location and set up your footcare consultation appointment.