Medical Information and Informed Consent to Treatment Document
INFORMED CONSENT:
As a Varsity Team Member,
I consent to the care and treatment by the athletic therapy clinic staff, and those supervised by the athletic therapist(s) (as defined by C.A.T. scope of practice) to myself, both in the clinic and during on-field play.
I am aware that my medical and/or fitness status may be disclosed by the varsity athletic therapist(s) to my coach, where required for my health care, and I give permission for this.
I understand that if I choose to seek medical advice external to the varsity athletic therapy clinic, for an injury or medical "condition" and, the "injury/condition" affects my ability to play, I do consent to being re-evaluated by the varsity athletic therapist before being cleared to return to play.
I understand that in order to facilitate this re-evaluation process, it is my responsibility to provide the varsity athletic therapy clinic with any test results and/or images from the external source, regarding the "injury/condition".
If there is a discrepancy of opinion concerning return-to-play between an external clinician and the varsity athletic therapist, I understand that the varsity athletic therapists clinician's decision will prevail.
I have been advised by the varsity athletic therapy clinic that an annual physical on myself is recommended, to determine health status and ability to play prior to participating in the team sport.
I am aware that failure to keep a booked appointment with the athletic therapy clinic and/or provide 1 hours notice of cancellation of appointment will result in a $20.00 NO SHOW fee to be charged.
The varisty athletic therapy clinic staff members are bound by conditions of employment, law and ethics to safeguard my privacy and the confidentiality of my personal information collected. Information will be disclosed to third parties only with my signed, written consent or when legally required.
