Physiotherapy Consent Form and Terms and Conditions

Dear Valued Client,

This document explains the general conditions under which Dain Wilson Physiotherapy (DWP) sees clients and serves as a binding contract between you, the client, and DWP. 

If this form is correct in all respects please tap 'Accept Offer' at the foot hereof.  If any changes are required, please tap 'Counter Offer' at the foot hereof, make the relevant changes and tap 'Make Offer' to send back to us. 

I , ID NumberPassport Number with my domicillum citandi et executandi at (please insert your physical address):

,

hereby authorise the service provided by DWP to myself or to my dependent.

Terms and condition

1. I hereby declare and warrant that the personal and medical information provided to DWP is both true and correct.

2. I acknowledge and understand that DWP is not a diagnostic medical facility and only provides performance testing including, but not limited to, muscle strength, gait analysis and heart and lung functioning.

3. This completed and accepted form serves as consent to such testing and as authorisation for ongoing services and/or repeat procedures.

4. I will be charged for all appointments not cancelled 4 hours prior to the appointment time.

5. DWP is obligated to protect personal information of clients, legally and ethically, at all times. I acknowledge and understand that:

5.1. no personal information will be disseminated to any third party without my expressed informed consent;

5.2. DWP shall collect, use, store and disclose protected health information and personally identifiable information in compliance with all applicable laws and regulations;

5.3. I hereby consent to and authorise the release of information required for the provision of this service and to recover sums owing on overdue accounts which thereafter falls outside DWP’s control;

5.4. I am entitled to obtain personal information contained within DWP’s records upon request.

6. I understand that this contract is entered into between DWP and me, and not any other third party. I understand that payment for services rendered by DWP remains my responsibility and I therefore agree to pay for all services rendered under this agreement immediately after the services and/or testing has been performed.

7. All arrear amounts owing shall attract interest at 2% above the prime interest rate charged by financial institutions from time to time. All payments shall be allocated first to interest, costs and thereafter to the capital sum owing.

8. I agree that in the event of any legal action being instituted against me, I will pay all legal costs on an attorney and client scale including all costs occasioned by the tracing and collection of all amounts claimed. 

9. I hereby consent to verification checks and agree to the disclosure of information relating to relevant credit bureaus in accordance with the provisions of the National Credit Act No. 34 of 2005.

10. Should I insist that services be rendered or materials be provided by DWP which is contrary to the advice or recommendations received from DWP, I acknowledge that I shall not hold the DWP, its employees or its associated persons and entities liable for any consequences which may be deleterious or not to my liking. I also acknowledge that should further work be necessary to remedy such consequences, I will be fully liable for any related costs.

11. To the extent permissible by law, in no event shall the DWP, Golds Gym, its employees and/or associated entities be liable for any direct, incidental and/or consequential loss and/or damage for any reasons whatsoever however caused.

12. The address stipulated herein shall be my chosen domicillum citandi et executandi for all purposes arising hereout. Should I change my address this shall become effective upon confirmation of receipt of the change of address notice by DWP.

13. No variation, representation or waiver howsoever made shall be valid unless reduced to writing and accepted by both parties.