Parental consent form

If you wish to leave your child alone at the office, you must fill out this form.

Consent to treatment

Please complete the following form.

Legal guardian’s first and last name

Child’s first and last name

Child’s date of birth

Month

Day

Year

Phone number

Do you authorise your child to receive physiotherapy at PhysioUnion without you being present during the session?

Yes

Do you authorise PhysioUnion to contact you if your input or consent is needed during treatment?

Yes

Declaration

By submitting this form, I declare that I hold parental responsibility or am legally authorised to represent the child named above.

I authorise my child to attend physiotherapy sessions at PhysioUnion without me being present, as part of the agreed and/or medically prescribed treatment.

I understand that sessions may include therapeutic exercises, mobilisations, manual techniques, functional activities or other techniques adapted to my child’s health and needs.

I understand that temporary effects may occur after a session, including fatigue, muscle soreness, local tenderness or a temporary increase in symptoms, and that no specific treatment outcome can be guaranteed.

I undertake to inform PhysioUnion of any significant change in my child’s health that could affect their treatment.

Confirmation

I confirm that the information provided is accurate and that I have the authority required to give this consent.

I confirm that I have read and understood the information above and authorise my child to receive treatment without me being present.

Initials