Patient Consent Form

Name

HK ID No./ Passport No.

I understand that the Personal information collected is based on the Personal Data (Privacy) Ordinance issued by the Hong Kong Government. The Data provided will only be used by Perfect Pointe Physiotherapy Limited and it will not be reviewed to the third party without patient’s consent.

In accordance with the Medical Clinics Ordinance Chapter. 343 No.8(1), patient should be referred by a physician or other medical professional or patient who is already in the middle of physiotherapy. In emergency situation, Physiotherapist may need to give physiotherapy treatment to patient without referral letter. Physiotherapy is not Physician, if patient need medication or medical check up or surgeries, patient need to consult a physician. Physiotherapist may refer patient to other medical specialist when needed.

I understand that I need to seek for advice from the concerned Insurance Company for the medical claims, terms and condition.

Appointment with the Physiotherapist of Perfect Pointe Physiotherapy Limited is on advanced booking basis. The concerned timeslot is reserved for each individual patient. Patient has to inform our staff at least 24 hours before the appointment if he/she needs to cancel or change the booking. Late cancellation (less than 24 hours notice) or missed appointments will be charged at the standard fee or deducted from package (if any).

In the physical assessment, patient may need to expose the related body part and during the manual therapy, therapist will need to have physical contact with patient’s body. If patient feel uncomfortable, patient must inform the therapist and he/she has the right to request for a third party attendance.

If patient has any question, he/she should contact our staff immediately.

I will pay by credit card or cash for any service or product of Perfect Pointe Physiotherapy Limited. I have read and understand the above statement. It is my own will to seek for service from the Perfect Pointe Physiotherapy Limited.

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