Pelvic Floor Therapy Form

Please complete the following intake form before booking a virtual consultation session with Mommy Monitor's Registered Physiotherapist, Andrea Meade. If you have any questions or concerns, please email: info@mommymonitor.ca.

Do you identify as a member of the African, Caribbean and/or Black community? (Note: We prioritize the health of these communities due to the disproportionately adverse health outcomes they experience).

Date of Birth
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How were you referred to us?
Consent to Tele-Rehabilitation

Tele-rehabilitation involves the use of electronic devices to enable 2-way communication between clients and their health practitioner at different locations for the purpose of diagnosis, therapy, follow-up and/or education. Transmitted information may include any of the following:

  • Client medical records
  • Live two-way audio and video
  • Client material such as exercise prescription and education materials may be sent to the clients via email upon request

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits

  • Improved access to healthcare and rehabilitation services by enabling a client to remain in their home or workplace for simple issues such as exercise prescription and education
  • More efficient evaluation and management

Possible Risks:

As with any rehabilitation procedure, there are potential risks associated with the use of tele-rehabilitation. These risks include, but are not limited to:

  • In rare case, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate rehabilitation decision making by the health practitioner and consultant(s);
  • Delays in rehabilitation evaluation and treatment could occur due to deficiencies or failures of the equipment;
  • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information

Alternatives

  • Clients have the alternative to access in-person care at the clinic location within their health practitioner's clinical office hours.

By signing the form, I understand the following:

  1. I understand the purpose, risks, benefits, and alternatives of tele-rehabilitation.
  2. I understand that I have the opportunity to ask any questions or concerns that I may have prior to my rehabilitation session.
  3. I understand that I am responsible for immediately telling the therapist if I am having any discomfort or unusual symptoms during my tele-rehabilitation session.
  4. I understand that the laws that protect my privacy and the confidentiality of personal health information and medical information also apply to tele-rehabilitation, and that no information obtained in the use of tele-rehabilitation which identifies me will be disclosed to researchers or other entities without my consent.
  5. I understand that I have the right to withhold or withdraw my consent to the use of tele-rehabilitation in the course of my care at any time, without affecting my right to future care or treatment.
  6. I understand that I may choose to make an in-person appointment at any time (booked within your practitioner's clinical office hours).
  7. I understand that my health practitioner may recommend I schedule an in-person appointment to address issues that cannot be adequately addressed through tele-rehabilitation.
  8. I understand that tele-rehabilitation involves encrypted electronic communication of my personal medical information.
  9. I understand that I may expect the anticipated benefits from the use of tele-rehabilitation in my care, but that no results can be guaranteed or assured.

Local Emergency Number: Your safety is our primary concern and as a tele-rehabilitation client, you may live anywhere in Ontario. Below are the local York Region Emergency Numbers:

Emergency (Fire/Medical/Police): 9-1-1 York Region Paramedics: 1.877.800.7924 Richmond Hill Fire Services: 905.883.5444 York Region Police 1.866.876.5423

Should you be outside of the York Region area, please provide your therapist with your local first responder emergency numbers (not 9-1-1). This best ensures your safety should anything happen while on a tele-rehabilitation call with your therapist.

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Centre for Social Innovation, 192 Spadina Ave, Toronto, ON, M5T2C2
www.mommymonitor.ca
info@mommymonitor.ca