MelioGuide – Consent Form
The assessment will include active participation in the evaluation of your:
- Balance and agility.
- Strength and cardiovascular fitness.
Your fatigue should be minimal and none if the exercises should cause you any discomfort. You may stop the assessment and exercises at any time. Any questions regarding the exercises and testing are welcomed.
What are your responsibilities?
I am aware that my involvement in this evaluation is completely voluntary. I am also aware that I may request to stop at any time.
I have read this form and I understand the assessment procedures that I will perform. I consent to participate in the above and I withdraw my right to make any claim of any kind against Margaret Martin, for any injury, illness or adverse change in my medical condition or state of health arising directly or indirectly from this course or the consequent training program.
I represent and warrant Margaret Martin that I have furnished details of any medical condition I have (or may have had) that would limit my full participation in this assessment and subsequent program. I have read the foregoing and I understand it.
I understand that, unless there is a medical emergency, I must provide 24-hour cancellation notice. Not doing so, I will be charged for my appointment in full.
MelioGuide Physiotherapy and Personal Training collects, uses and discloses health information according to the Personal Health Information Privacy Act. MelioGuide may disclose personal and health information:
- To you (just ask).
- To your agents and representatives as designated in writing by yourself.
- To physicians or other health care professionals or health care providers involved in your treatment and care (under your consent).
- To other organizations as mandated by other provincial or federal laws.
MelioGuide is committed to:
- Taking steps to protect your personal health information from theft, loss and unauthorized access, copying, modification, use, disclosure and disposal.
- Protecting your privacy and only uses your personal health information for the purposes to which you consent.
Withdrawing consent: I understand that I may withdraw my consent, in whole or in part, at any time upon providing written notice. If I withdraw my consent, I understand that this is not retroactive, and does not apply to personal or personal health information already collected, used, or disclosed by MelioGuide.
I have read the above authorizations and indicate my consent by my signature below. My consent is valid unless and until I withdraw it in the manner set out in this consent form.