Consent Form | Axion Health Portal

Nature of Services

Axion Integrated Health provides chronic pain care and rehabilitation services through a multidisciplinary team. Depending on your needs and the professionals involved in your care, services may include assessment, education, exercise-based rehabilitation, manual therapy, functional rehabilitation, psychological or behavioural health support, occupational therapy, care coordination, pain-management planning, documentation, reports, and communication with authorized third parties.

Your specific care plan will depend on your assessment findings, goals, clinical judgment, professional scope of practice, and your consent.

Consent to Assessment and Treatment

I consent to clinical assessmentI consent to treatment planningI consent to hands-on care when clinically appropriateI consent to exercise / functional rehabilitationI consent to care coordination among authorized providersI consent to outcome measures and progress tracking

I understand that I may refuse any part of an assessment or treatment. I may ask for a pause, modification, chaperone, explanation, or different provider where possible.

Potential Benefits

Possible benefits may include reduced pain, improved mobility, improved strength, improved function, better understanding of symptoms, improved coping strategies, better return-to-work or return-to-activity planning, and improved quality of life. Results are not guaranteed.

Material Risks and Side Effects

All care has potential risks. Risks vary depending on the service, your condition, and your health history. Risks may include temporary soreness, fatigue, symptom flare-up, bruising, dizziness, headache, emotional discomfort when discussing pain or trauma, skin irritation from tape or equipment, aggravation of a pre-existing condition, falls during exercise, delayed recovery, no improvement, or the need for medical referral. Rare but serious risks may include significant injury or medical complications. Emergency symptoms should be reported immediately or assessed through urgent/emergency care.

Alternatives

Alternatives may include no treatment, monitoring symptoms, care from your family doctor or nurse practitioner, specialist referral, medication management, imaging or investigations when medically indicated, hospital or urgent care, or treatment from another regulated health professional. You may discuss alternatives with your clinician.

Patient Responsibilities

Provide accurate health informationUpdate the clinic about new symptoms or medicationsReport pregnancy or possible pregnancy when relevantFollow home-care instructions within toleranceStop exercises that feel unsafe and contact the clinicAttend appointments or provide proper cancellation notice

I understand that incomplete or inaccurate information may affect safety, treatment decisions, billing, reports, and outcomes.

Privacy and Health Information

I authorize Axion Integrated Health to collect, use, and store my personal health information for assessment, treatment, care coordination, billing, scheduling, documentation, quality assurance, and professional/legal compliance. My records will be kept confidential and disclosed only with my authorization or where permitted or required by law.

People or organizations I authorize Axion to communicate with (if any)

I authorize communication with

Restrictions on disclosure (if any)

Electronic Communication

I understand that email, text message, voicemail, online booking, and electronic forms may carry privacy risks. I consent to reasonable electronic communication for scheduling, reminders, forms, receipts, general clinic communication, and care coordination unless I tell the clinic otherwise in writing.

Email permittedText / SMS permittedVoicemail permitted

Communication preferences (optional)

Fees, Missed Appointments and Reports

I accept responsibility for fees not paid by insurance or third parties, including assessments, treatments, supplies, reports, forms, records, missed appointments, late cancellations, and administrative services where applicable. The clinic may require payment at the time of service unless other written arrangements are made.

No Guarantee

No promise or guarantee has been made about diagnosis, recovery time, pain reduction, insurance approval, legal outcome, return to work, or any other result. Treatment recommendations are based on clinical judgment and may change as new information becomes available.

Acknowledgement and Signature

I have read and understood this informed consent form. I had the opportunity to ask questions. I understand the nature of services, potential benefits, potential risks, alternatives, privacy practices, communication options, and fees. I consent to assessment and treatment at Axion Integrated Health.

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Parent / Guardian (if applicable)

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