Informed Consent to Osteopathic Manual Therapy
I understand that the practitioner identified below provides osteopathic manual therapy within their education, training, and permitted scope of practice.
I voluntarily consent to receive osteopathic manual therapy for the purposes discussed with me. This may include assessments, movement examinations, palpation, manual techniques, stretching, and other approaches recommended by the practitioner and accepted by me.
I understand that the practitioner is not a physician and does not diagnose diseases, illnesses, or physical or mental health disorders.
I understand that osteopathic manual therapy is not a substitute for medical examination, diagnosis, or treatment. I have been advised to consult an appropriate regulated healthcare professional regarding symptoms, injuries, medical conditions, or other health concerns when necessary.
The practitioner has explained the nature and purpose of the proposed assessment and treatment, the expected benefits, reasonably foreseeable risks and possible discomforts, and available alternatives, including the option of receiving no treatment.
I understand that results cannot be guaranteed and that individual responses to treatment may vary.
I understand that temporary soreness, tenderness, stiffness, fatigue, bruising, light-headedness, or other mild reactions may occur after treatment. I agree to inform the practitioner immediately of any pain, discomfort, dizziness, numbness, breathing difficulty, or other unexpected symptoms experienced during the session.
I understand that the practitioner must be informed of my relevant medical history, current symptoms, injuries, medications, pregnancy status, surgeries, allergies, and other conditions that may affect the safety or suitability of treatment.
I confirm that I have completed the health history form accurately and have disclosed all relevant information to the best of my knowledge. I understand that it is my responsibility to inform the practitioner of any changes to my health or medical history before future appointments.
I confirm that the information I have provided is true and complete to the best of my knowledge.
I understand that my personal and health information will be collected, used, stored, and disclosed only as permitted by law and in accordance with the practice’s privacy policy.
The practitioner may release or obtain information relating to my condition or treatment only with my consent or when otherwise permitted or required by law. Separate consent may be requested before information is shared with another healthcare provider, insurer, or third-party payer.
I confirm that I have read and understood this form and have had the opportunity to ask questions about the proposed assessment and treatment. My questions have been answered to my satisfaction.
I understand that consent is voluntary and may be limited, changed, or withdrawn at any time. If I withdraw consent, the assessment or treatment will be stopped.
By signing this form, I voluntarily consent to the assessment and osteopathic manual therapy discussed with me. I understand that consent for future sessions will continue to be confirmed verbally and that a new consent discussion may be required if the treatment plan, techniques, risks, or areas being treated change.
Post-Treatment Confirmation
At the conclusion of today’s appointment, I confirm that I had the opportunity to discuss any questions, discomfort, or concerns with the practitioner.
To the best of my knowledge, I have no immediate concerns regarding the assessment or treatment provided today. I understand that this confirmation reflects my condition at the conclusion of the appointment and does not prevent me from reporting concerns or unexpected symptoms that may arise later.
If I experience unexpected, severe, or worsening symptoms after leaving the appointment, I understand that I should contact the practitioner and seek appropriate medical attention when necessary.
