Client profile

Contact info

Full Name:

Halina Przywara

Parent/Guardian Name:

Birth Date:

Gender:

F

Address:

300 Selkirk ave

City:

Winnipeg

Postal Code:

Province:

MB

Phone:

2048979849

E-mail:

n/a

R2W 5H7

Patient History

Date:

Reason of appointment:

Treatment

Main complains:

Main complains: hip stiffness, lowerback pain, hands joints soreness and stiffness, feet pain.

Environmental factors:

List of medications:

MD contacts:

Stress level:

Pain level:

Allergies:

Other practitioners:

Patient history:

Patient history (details):

Living habits:

Living habits (details):

Health history:

Arthritis

Health history (details):

Present condition:

Difficulty sleeping / Insomnia

Present condition (details):

Problem locations:

Head, Lower Back, Right hip, Left hip, Right foot, Left foot

Problem locations (details):

Contraindications:

Contraindications (details):

INFORMED CONSENT

I                                                                 voluntarily give my informed consent to Osteopathic Manual Practitioner for the Osteopathic Care.

 

I acknowledge that the Osteopathic Manual Therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. I clearly understand that osteopathic manual therapy is not a substitute for a medical examination. It is recommended that I attend my personal physician for any ailments that I may be experiencing.

I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment. I acknowledge that with any treatment there can be risks and those risks have been explained to me and I assume those risks. I do not expect Osteopathic Manual Practitioners to be able to anticipate and explain all risks and complications. With this knowledge, I voluntarily consent to Osteopathic care. I intend this consent form to cover the entire course of treatment. I understand that I am free to withdraw my consent at any time.

I understand that a confidential record will be kept of the health services provided to me. This record will be kept confidential but if required, I understand that my Osteopathic Manual Practitioner may discuss my case with other healthcare providers. I consent to this file being shared with other Health Care Professionals if required. I understand that information from my medical records may be analyzed for research purposes and that my identity will be protected and kept confidential.

It is the responsibility of the patient to inform the practitioner of any pre-existing medical conditions, possible contraindications, any risks, injuries or disease of which patient are currently aware of. It is the right and responsibility to inform the practitioner of your condition, side effects during the session and, course of the treatment. The Osteopathic Manual Practitioner reserves the right to discontinue services where it is apparent that your expectations and the type of services provided are not compatible.

Treatments may include manual therapies where the health practitioner places the hands on the body. Many techniques will involve contact between patient`s body and the practitioner's body. Body and hand contact may include areas of your chest wall, pelvic floor, and pubic bones, inner thigh, gluteal area. If intraoral work is required (work inside the mouth), disposable latex or vinyl gloves will be worn. At times, the practitioner may ask the patient to remove some items of clothing in order to facilitate treatment. If you do not feel comfortable with any part of the treatment, please inform immediately. The techniques can be discontinued or modified to be comfortable for you. 

Your appointment has been reserved especially for you, however, if you need to cancel your appointment, out of respect for your therapist and your fellow patients, we ask that you provide the clinic with at least 48 hours advance notice. Cancellations with less than 48 hours’ notice are subjected to a charge of 100% of the fee for the service scheduled. If you do not attend a scheduled appointment and do not call (text, email) to cancel or reschedule ("no show"), you will be charged 100% service fee.

I understand and agree that the health insurance policies are an arrangement between an insurance provider and myself.  Furthermore, I understand that the health practitioner will prepare any necessary reports and forms to assist me in making collection form the insurance carrier.  However, I understand and agree that all services rendered to me are charged directly to me and that I am responsible for payment personally.  I also understand that if I suspend my care or terminate my care at this office, any outstanding charges for professional services (including 100% fee for the current appointment)  will be immediately due and payable.

Halina Przywara

Signature:

Date:

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