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Pelvic Floor Exam Consent Form 

I understand that I will have the opportunity to give/revoke my consent at each treatment session. 

I understand that I may have a person of my choice accompany me during the evaluation, and that the exam will occur in clean, private & secure area.

I understand that I will be required to disrobe for the exam and that appropriate draping and coverings will be provided.

I will communicate relevant medical history information to the therapist including, but not limited to, medication use, IUDs (or other implants), pre-existing urogenital infection or known sexually communicable diseases. 

I understand that this examination is performed by observing, palpating or inserting a gloved finger into the perineal region including the vagina and/or rectum. This evaluation will assess skin condition, reflexes, muscle tone, length, strength and endurance, scar mobility and function of the pelvic floor region.

Treatment may include, but is not limited to the following: observation, palpation, use of vaginal weights, vaginal or rectal sensors for biofeedback and/or electrical stimulation, ultrasound, heat, cold, stretching and strengthening exercises, soft tissue and/or joint mobilization and educational instruction. 

Potential risks: I may experience an increase in my current level of pain or discomfort, an aggravation of my existing injury or minor bleeding. These effects are usually temporary; if they do not subside in 1-3 days, I agree to contact my therapist or physician. 

General Consent Form

Physiotherapy is an effective and safe form of therapy. However, like most interventions along with the sought benefits of treatment there are possible side effects, and responses to treatments are unique per individual. Your physiotherapist will provide you with information about a treatment, along with the associated risks and benefits. Our physiotherapists are skilled and should be able to offer a variety of treatments to ensure you get results in a way that you feel comfortable with.

You may choose to withdraw your consent at any time for whatever reason. This practice is committed to complying with the Privacy Act 1998 and the Australian Privacy Principles 2014.

Every individual has a unique rate of healing and response dependent on many factors, such as health, co-morbidities, periods of adequate rest etc. If you are concerned about your response to treatment, you are encouraged to discuss this with your physiotherapist.

If you have suggestions, comments, or complaints, we encourage you to inform our staff or submit in writing.

ACCOUNTS/FEES Private patients are required to cover their fees at the time of service. We have installed HICAPS facilities for automatic and instant health fund claims to make this easier for you.

SCHEDULING AND MISSED APPOINTMENTS Your physiotherapist will develop a plan with you that takes into consideration your lifestyle and goals of treatment. It is of benefit to you that you are able to schedule your appointments in advance to ensure you can adhere to the plan to the best of your ability, as well as reserving a place in the physiotherapist’s schedule. Although we will do our best to reschedule, missed appointments can delay your recovery. If an appointment must be changed, 24hours notice is appreciated. 

INFORMED CONSENT Once you have given consent you may withdraw that consent at any time Your condition and treatment options will be discussed so that you are appropriately informed and, together with your physiotherapist, can make decisions relating to your treatment. You are entitled to refuse any form of treatment and are encouraged to communicate any concerns with your physiotherapist.

PERSONAL QUESTIONS It is your choice what and how much you choose to disclose In order to obtain a clear picture of you injury and impact on activities of daily living or function, your physiotherapist may ask questions of a personal nature. The more relevant information you provide gives your physiotherapist details to create a specific and effective treatment plan for your requirements. Our staff adheres to the privacy and confidentiality act, but also understands the trusting relationship that is required for such disclosure of your personal information, and endeavor to treat this material with the upmost respect.

PHYSICAL CONTACT If you feel uncomfortable at any time please inform your physiotherapist It is likely that physical contact will be necessary during the course of examination, assessment and treatment. Again, you may withdraw your consent at any time and any physical contact will cease immediately. Please inform your physiotherapist if anything can be done to assist your comfort or if you have any concerns.

CHILDREN For the treatment of a minor this form must be signed by a custodian. Presence of a parent or caregiver is requested for anyone under the age of 16 years receiving treatment.

RISKS Foreseeable risks will be discussed with you prior to administering treatment. Again, you may withdraw your consent at any time or request further treatment options.

Consent and Privacy: Consent for Treatment
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