Patient Privacy Document

I, ________________________________________________________________understand that:



  1. I am attending CityPhysio for physiotherapy assessment, evaluation and treatment. This will consist of history taking, movement analysis,  various tests and measurements;
  2. Treatment recommendations may include but are not limited to advice, manual therapy, acupuncture, electrotherapy, education, exercise and/or onward referral if necessary;
  3. The exercises may include stretches, general movements, strength and conditioning work in the gym, and self-treatment at home;
  4. The physiotherapist will explain the most recent research and clinical reasoning behind each of the treatment interventions, inform me of any potential risks, and options I have for alternatives;
  5. I can ask my physiotherapist questions at any time;
  6. I can stop my assessment or treatment at any time;
  7. I have read, understood, and had the opportunity to discuss the Patient Informed Consent document with my physiotherapist.


Personal information that Cityphyio collect, retain, use and disclose may include without limitation, your age, contact information, occupational information, personal health information, medical history and other information deemed necessary to fulfil the following purposes:

  1. To provide assessment and treatment services.
  2. To provide/obtain to/from doctors, other medical professionals, third party payers, and legal counsel with/from progress reports, assessment findings, diagnostic tests/medical investigations, resulting from the services provided to you or in order to optimize the treatment to be provided to you.
  3. To contact you about appointment reminders and follow-up calls.

My signature below indicates my understanding of all the above information and that I am aware of CityPhysio’s practice privacy statement.


____________________________________________                                                                          _________________

Patient Signature:                                                                                                  Date:

☐ Please tick if you are happy for us to contact you about services we are offering. This may include newsletters promotions and events.

If under 16 years of age, this consent form must be completed by a parent or guardian.