Holistic Pelvic Care
PATIENT CONSENT/TERMS & CONDITIONS
CANCELLATION AND NO SHOW POLICIES: Because of the nature of this work, you should anticipate a limited number of sessions. Generally patients should expect between one to three appointments. If you require additional work, you may need to seek another care provider. Cancellation with less than 24 hours notice will result in full payment being charged.
PELVIC FLOOR EVALUATION/TREATMENT; If you are receiving a pelvic floor assessment, this assessment includes and internal vaginal exam to asses pelvic musculature health. Subsequent visits for treatment of findings may include internal vaginal massage, instruction in pelvic muscle and breathing exercises, rectal assessment, massage and other techniques as needed. I understand and consent to these services, to be provided at the discretion of therapist. I also understand there is no guarantee of outcome of any treatment. Patients may experience a range of effects as a result of treatment including many benefits but also physical effects such as soreness or bleeding, as well as emotional responses to the treatment. I understand and agree that if at any time I experience symptoms that concern me or difficulty integrating a pelvic session, I will promptly consult my treatment provider (primary care physician or counsellor, as applicable).
PRIVACY PRACTICES AND RELEASE OF INFORMATION; If i request submission of my medical records to any third party (e.g health care providers, case managers, insurance representatives, lawyers) I understand I will need to provide a signed release prior to the transmission of medical records or any discussion between Melissa Clare and any third party about my treatment. I have the right to receive a written Notice of Privacy Practices should I request it.
By signing below, I consent to evaluation and/or treatment of my condition by Melissa Clare. I understand the nature and the purpose of the procedures, evaluation and course of treatment. I have been given the opportunity to ask questions, and my questions have been answered to my satisfaction. I certify that I have read, fully understand, and agree to the terms of this consent form.
You must agree to these terms & conditions prior to booking your appointment.