Hand Therapy Consent Form

HAND THERAPY CONSULTING

CONSENT FORM

 

ONLINE CONSENT

I understand that I have the following rights with respect to an Online Consultation:

1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

2. The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. 

 

PRACTICE CONSENT

I understand that I have the following rights with respect to receiving treatment at Hand Therapy Consulting.

 

CONSENT TO PRACTICE PROCEDURE

The following must be adhered to when attending Hand Therapy Consulting:

1. Hands must be washed upon entering the practice. Single-use towels will be provided.
2. Hand Therapy Consulting will sanitize the treatment table and equipment before and after each patient has attended their session.
3. Robyn Midgley will wear gloves and a mask if you are unwell or have an infection.
4. All towels will be single-use.

 

CONSENT TO THE USE OF DIGITAL PHOTOGRAPHY

I hereby authorize Robyn Midgley to utilize photographic or video records.

These records will relate to my treatment before, during and after treatment to be utilized for:

• Scientific, educational presentations
• Practice marketing (in-office material)
• Website
• Social Media Platforms (Youtube, Facebook, Instagram) Anonymous if desired.

 

CONSENT TO THE USE OF SPECTROCHROMETRY, ULTRASOUND, LIGHT THERAPY & VIBRATIONAL MEDICINE USING A CRYSTAL AMPLIFYER

I hereby acknowledge that Robyn Midgley uses advanced therapeutic modalities and technqiues such as Ultrasound, the spectrochrome laser, nanotechnology & vibrational medicine in the form of tuning forks. The equipment that is used is state of the art and has been invested in for the sole use of expediting the healing process. The use of these modalities are include din the consultation fee. They are used at Robyn's discretion and are evidence-based. Robyn's philosophy is to heal patients in the fastest time possible, hence the investment in her equipment as well as he knowledge, skill and expertise. All treatment that is provided at Hand Therapy Consulting is evidence-based. Results are usually achieved at the first consultation, but 3-6 additional sessions may be needed to fully heal the injury. Due to the nature of the assessment and the application, video's are taken with voice-overs which form part of the medical notes. Robyn also uses AI POPIA and HIPPA compliant software to assist with note taking. Robyn enjoys explaining the science begind the use of these modalities should it interest you. She has also developed a learning platform for patients to gain a deeper understanding of the science and application of these techniques. 

I also acknowledge that when I consent to having physics-based medicine, I will be required to lie down on the plinth to receive the treatment. A full body treatment may be warranted. I understand that Robyn has undertaken additional post graduate training to implement this type of assessment and treatment. 

 

CONSENT TO PRACTICE FEES

Please note the following information with regards to the practice fees charged by Hand Therapy Consulting.

Service Agreement:

This practice’s service is rendered to the patient and not their Medical Aid.
Medical Aid rates are not charged and accounts are not submitted to the Medical Aid on your behalf.
The consultation fee does not include the use of splints or materials.
Patients / Guardians are personally responsible for settling their account in full at the end of each consultation.
 

Rates:

This practice does not charge the rates that the Department of Health has unilaterally determined for specialists which are known as the Reference Price List (RPL).
You will be provided with a detailed account with all the relevant codes required by law, to submit to your medical aid.
All charges will be outlined and explained at the time of your consultation.

 Debt:

Should an account not be paid within 7 days of the due date you will be liable towards the following penalty fees:
 i.     2% interest per month until the account has been settled.

 ii.     A handover fee of R350.00 should we need to hand the account over to our collection agency due to non-payment.

Any account that has not been settled in full withing 60 days will be handed over to our pre-legal representatives where you will be held liable for all legal fees and expenses incurred.

Forms / Reports:

The completion of medical insurance forms or reports is not part of your consultation and will be charged for accordingly. The fee is R1060 per half hour. The time needed to complete the report will be determined upon request for a report.

Confidentiality:

All information handled by this practice will be regarded and treated as strictly confidential by the therapist and administrative staff. Confidentiality may not be absolutely preserved, as this practice is required by law to disclose all the relevant ICD-10 codes (diagnostic coding format) on accounts, prescriptions, referral letters and requests for investigations.

Should you not be satisfied with the service that you have received, the practice requests that you contact Robyn Midgley either by phone or by email and express your concerns.

Please use Robyn as your first option to rectify the situation or address your concerns.

All conversations that take place in the consulting rooms must remain strictly confidential.

 

NON ATTENDANCE AND CANCELLATION PROCEDURE

 

Following a hand injury or surgery, it will be necessary for you to attend Hand Therapy on a regular basis for an average of 3 months or longer depending on the severity of the injury or surgery.  This is to ensure you receive timely, effective treatment and to maximise your recovery so that you have the best chance to return to your previous activities.  It is therefore essential you comply with the therapy program.

 

Cancelling appointments:

If you cannot attend your appointment please advise me as soon as possible or notify me at least 24 hours prior to your appointment.  This will enable me to offer this time slot to another patient ensuring the most efficient use of the therapy service and to reduce the overall waiting times for all patients. A text message reminder is sent the day before your scheduled appointment. Any appointments that are not cancelled with 24 hours notice will be charged for. Medical aids do not cover the cost of missed appointments.

 

Please arrive promptly for appointments:

Attending your appointment on time will ensure you get the maximum benefit from your therapy input.  If you are 15 minutes late for your appointment please expect your appointment to be cancelled and re-booked as we need to meet following appointments on time, so that the next patient’s treatment is not compromised.

 

Consultation Fees:

The initial consultation fee is R1680.00 This appointment lasts between 30 - 60 minutes. 

Follow-up consultations are charged at R1060.00 and lasts 30 minutes. In certain circumstances, patients will require 60-minute follow-up consultations. This will be discussed when planning your treatment and will cost R1680.00 per hour.

The consultation includes the use of a variety of modalities and equipment. Materials and splints are charged for in addition to the consultation fee.

If you have any queries about the above please do not hesitate to discuss this with me.

I have read, understood and agree to the conditions mentioned above.

I accept that this information was provided electronically at the time of making my initial appointment and I give electronic consent to the practice terms and conditions.

 

Thank you for your participation.

   

Robyn Midgley

Clinical Specialist in Hand Therapy

BSc (Hons) OT, AHT (BAHT), ECHT (EFSHT)