Consent for Athletic Therapy Services
This form is to show consent for Certified Athletic Therapy Services and billing for services provided at St. Michaels University School/Ozmosis Wellness Inc.
Parent/Guardian's Full Name *
Your answer
SMUS Student's Full Name *
Your answer
SMUS Student Number *
Your answer
The Scope of Practice of a Certified Athletic Therapist includes the prevention, immediate care, and reconditioning of musculoskeletal injuries. Prevention includes musculoskeletal and postural evaluation, equipment selection, fitting and repair, warm-up, conditioning programs, prophylactic or supportive taping, and adapting to the activity environment and facilities. A Certified Athletic Therapist assesses injuries and conditions, uses contemporary rehabilitative techniques, therapeutic modalities, soft tissue mobilization, physical reconditioning, and supportive strapping procedures to promote an environment conducive to optimal healing in preparing the individual for safe reintegration into an active lifestyle. Manual Therapy Techniques Mulligan Techniques, Manual Mobilizations, Graston Technique, Active Release Technique, Muscle Energy Technique, Myofascial Release Technique, Massage, Interferential current, TENS, *
I understand the scope of practice and consent to my child's Athletic Therapy Treatment at St. Michaels University School
I understand that my son/daughter has sustained an injury which they have requested treatment by a Certified Athletic Therapist at St. Michaels University School. 30 minute appointments - $60.00, 45 minute appointments - 80, 60 minute appointments - $100. To be billed directly to your St. Michaels University School account. *
I consent to the charges per visit for Athletic Therapy Services to my son/daughters school account. Prices include gst.
Every extended health insurance policy has variability. *
I understand that it is my responsibility to check my extended insurance policy for coverage for a Certified Athletic Therapist. I understand that I can use the receipt provided from Ozmosis Wellness Inc. to submit for insurance coverage.
Every extended health insurance policy has variability. Con't *
I understand that it is my responsibility to have a doctors referral for treatment for Certified Athletic Therapist if my insurance coverage expects it.
Date *
MM
/
DD
/
YYYY
SACSL Consent** *
Required
Submit
Never submit passwords through Google Forms.
This form was created inside of St. Michaels University School. Report Abuse - Terms of Service