The Acupuncture Room – Informed Consent Form
Acupuncture, Physiotherapy, Massage and Chiropractic treatment are generally effective and safe forms of treatment however like any treatment there are benefits and risks. The purpose of this form is to let you know what your rights are and how we address the issue of collaborative decision making and informed consent between practitioner and patient.
Practitioners in this practice will discuss your condition and options for treatment with you so that you are appropriately informed and can make decisions relating to treatment. You may choose to consent or refuse any form of treatment for any reason including religious or personal grounds. Once you have given consent, you may withdraw that consent at any time. You have the right to see the practitioner of your choice.
Practitioners have the right to refuse to provide a service where there are reasonable and non-discriminatory reasons for doing so.
Questions of a personal nature: Your practitioner may ask personal questions relating to your condition and how your condition impacts on your ‘activities of daily living’. The more information you provide, the more likely it is that the practitioner can provide an effective treatment. It is your choice as to what information you choose to provide. If you feel uncomfortable with a particular questions or group of questions, please let the practitioner know and they will cease.
Physical contact: During the examination, assessment and treatment it may be necessary for your practitioner to make physical contact. Your practitioner will ask your permission before making physical contact in any way. Wherever possible, contact will be made using a towel or other forms of screening. Physical contact requires your express consent. You may withdraw consent at any time at which point, all physical contact will cease immediately. Please inform your practitioner if you feel uncomfortable at any time.
Risks related to treatment: As with all forms of treatment, there are risks and benefits. The practitioner will discuss any foreseeable risks with you prior to administering treatment. In some cases, the practitioner may ask you to read information related to a particular treatment and they may request that you sign a further consent form. This is to ensure that you fully understand any risks involved. You may withdraw your consent at any time even if you have previously signed a consent form.
Children and minors: Consent from a custodial parent is required to treat a minor (less than 18 years of age).
Substituted Consent: Where a person is incapable of understanding the risks and benefits of treatment, consent may be provided by another person legally authorised to provide such consent. Evidence of legal authorisation is required in such circumstances.
The Acupuncture Room – Privacy Policy
Your Personal Health Information and your Health Record may be collected, used and disclosed for the following reasons: for communicating with other treating health professionals, for follow-up/ reminder calls, for discussion with third party insurers, for health insurance procedures, for use by all practitioners in this practice, when consulting with you and for legal disclosure as required by a court of law.
If you have any concerns or wish to restrict access to your information, please discuss these with your practitioner or receptionist. This practice adheres to National Privacy Principles (www.privacy.gov.au) and has a written policy available for your perusal.
The Acupuncture Room – Practice Policy
At The Acupuncture Room, our goal is to deliver an exceptionally caring and prompt, professional service providing you with the best in acupuncture, physiotherapy, massage and chiropractic care. Our experience tells us that there are some key areas we need to focus on to ensure that you receive the greatest benefit from our services.
Mobile Phone
Out of respect for others, please turn off your mobile phone.
Healing
Remember that healing and correction take time and not everyone heals at the same rate. If at any time during your care, you do not feel that you are responding as well as expected, please discuss this with your practitioner. We want you to get the most from your care at The Acupuncture Room.
Financial Arrangements
Fees for patients are due at the time of service. HICAPS and EFTPOS facilities are available at the front desk for automatic claiming through Medicare or your private health fund. Not all insurers reimburse the full amount of the fee charged and therefore you will be liable for any gap payment.
Referrals
If you are really happy with our service and care, please let your family and friends know, so we can provide the same care to help with their health needs. They will benefit and we greatly appreciate your referral.
Appointment Scheduling/Missed Appointments
Your practitioner has decided on the best plan for your injury and it will heal best when you keep to this schedule. To receive the most out of your care and to save time, please schedule your appointments in advance. Missed appointments will set you back in your recovery, so we ask that wherever possible you keep all your appointments. All appointment changes, missed appointments or cancellations made within 48 hours of the scheduled appointment will be charged to you in accordance with our Cancellation Policy. This fee is not covered by compensable bodies and must be paid by the patient.
Initial Consultations
All new patients undergoing Acupuncture, Physiotherapy or Chiropractic treatments must book in for a Consultation and Treatment appointment (not treatment only). Patients who have not received treatment at our clinic for more than 12 months must book a Consultation and Treatment appointment (not treatment only).
Cancellation Policy
Your consideration would be appreciated.
Please read through The Acupuncture Room’s cancellation policy carefully. Every care is taken to ensure that you receive your service and treatment by a qualified practitioner, whom we are obligated to pay whether you show up or not. This policy also assists us to ensure that we can accommodate another client who may be in urgent need of our services.
| Deposit | Paid at time of booking.
Payment of $50 is required (for new acupuncture, new physiotherapy and new chiropractic patients only). Payment of $20 is required (for massage patients only). |
| Making changes to or cancelling existing appointment with more than 48 hours’ notice of the scheduled appointment: | No fee is charged. |
| Not showing or, making changes to, or cancelling existing appointment with less than 48 hours’ notice of the scheduled appointment: | You will be charged a fee of $35.00 |
| Prepaid Package Purchases: Not showing or, making changes to, or cancelling existing appointment with less than 48 hours’ notice of the scheduled appointment: | Loss of session. |
Refund Policy
When purchasing products please choose carefully.
No refunds given on services or products just because you change your mind.
You can choose between a refund, exchange or credit note where goods are faulty, wrongly described or different from a sample shown to you.
For Deposits:
Appointments cancelled or changed before 48 hours of the scheduled appointment will result in a full deposit refund for that appointment.
Not showing or, making changes to, or cancelling your existing appointment with less than 48 hours’ notice of the scheduled appointment will result in no deposit refund. This is help cover clinic and practitioner costs.
For Prepaid Package Purchases:
Prepaid Package Purchases are non-refundable.
Please retain your receipt for proof of purchase.
Hydration
We believe keeping well hydrated is important for your health, so we provided filtered drinking water. Please ask staff if water has not already been given to you.
Young Children
While you are receiving treatment, it is essential that young children are kept safely under supervision.