Welcome to Kimberly Rau & Associates Inc. We want you to understand and consent to the services we provide to you, the costs involved, and know what we do with personal information we obtain about you. Please read the following information and if you have any questions, please ask.
CONSENT FOR TREATMENT
Our health care practitioners are trained professionals licensed by regulatory bodies for their specific profession to provide treatment for health related concerns. Assessment and treatment will include observation and physical examination and possibly casting and fitting of foot orthotics. The treatment services you undergo may be administered by the treating professional and by pedorthic students under the supervision of the treating professional. By signing this form, you agree to our treatment.
CONSENT FOR THE COST OF OUR SERVICES
By signing this form, you agree:
● to pay for all services when they are provided
● if you do not pay for a service at the time it is received, to pay interest on any outstanding balance at the rate of 2% per month and, on default of payment, to pay al costs of recovering the debt, including legal and/or agent costs
● to provide a minimum of 24 hours’ notice if you must cancel an appointment. A fee will be charged for any late cancellation or no-show appointment according to the type of appointment booked. Your appointment time is reserved exclusively for you and our professionals cannot use this time to see other patients.
CONSENT TO COLLECT AND DISCLOSE PERSONAL INFORMATION
Kimberly Rau & Associates Inc. will collect some personal information about you (including without limitation, your name, age, contact information, health benefit information, occupational information, personal health information, medical history, etc.) in order to provide you with rehabilitation services and products. A copy of our Clinic Privacy Policy is available which contains additional information about the collection, use, disclosure, retention and accuracy of personal information, steps taken to protect the information, and your right to review your personal information. Please ask if you wish to read/review our Clinic Privacy Policy. By signing this form you agree that:
● Kimberly Rau & Associates Inc. may collect, use, and disclose personal information about you as set out in this form and in our Clinic Privacy Policy
● You understand how our Clinic Privacy Policy applies to you
● You have had an opportunity to ask any questions you have about our Clinic Privacy Policy and they have been answered to your satisfaction
● You understand there are some rare exceptions to the commitments in our Clinic Privacy Policy, as explained in the Policies and Procedures for Personal Information issued by the Government of Canada
● We may exchange (release and receive) your medical records with your attending physician, insurance company, legal representatives, employer, the Workers Safety Insurance Board and any other Health Care Professional relevant to your care
I have read the Consent Form above and I agree to Kimberly Rau & Associates Inc. collecting, using, and disclosing personal information about me as set out above and in the Clinic Privacy Policy of Kimberly Rau & Associates Inc.