Informed Consent
Physiotherapy, Chiropractic, Osteopathic, Podiatry treatment and Massage Therapy, including spinal manipulation or adjustment, has been the subject of government reports and multi-disciplinary studies conducted over many years and has been demonstrated to be effective for spinal pain, some headaches, and other similar symptoms.

Although no guarantee of treatment success can be given, physiotherapy, chiropractic, osteopathic, podiatry and massage therapy have stood the test of time. The risk of injuries or complications from physiotherapy, chiropractic, osteopathic, podiatry and massage care is lower than that associated with many medical or other treatments, medications, and procedures given for the same symptoms.

However, physiotherapists, chiropractors, osteopaths, massage therapists and medical doctors who use manual therapy techniques such as spinal manipulation or adjustments are now required to advise patients that there are or may be some risks associated with such treatment.

In particular, you should note:

1. Temporary soreness after treatment may occur in about 1 in 3 patients. Strains and sprains of the muscles, ligaments and other soft tissues do occur occasionally. While rare, some patients have also experienced rib fractures;
   
2. There have been reported cases of injury to a vertebral artery following neck manipulation / adjustments. Vertebral artery injuries have been known to cause stroke, sometimes with serious neurological impairment, and may on rare occasion result in serious injury or death. The possibility of such injuries resulting from neck manipulation / adjustment is extremely rare;
   
3. Although uncommon, there have been some reported cases of disc injuries following manipulation / adjustment of neck or lower back.

I acknowledge I have discussed, or if I so wish will have the opportunity to discuss, with my Physiotherapist, Chiropractor, Osteopath, Podiatrist or Massage Therapist the nature and purpose of physiotherapy, chiropractic, osteopathic, podiatry and massage treatment in general and my treatment in particular (including spinal manipulation) as well as the contents of this consent. I may do this at any time during my care at City Clinic.

When I submit this new patient form I consent to treatments offered or recommended to me by my City Clinic Healthcare Provider including spinal manipulation / adjustment if required. I intend this consent to apply to all my present and future healthcare at City Clinic. However, I may revoke or qualify this consent at a later time in writing. This consent does not prevent me seeking damages for injury caused by negligent treatment.

Please read the following carefully

You acknowledge your understanding of our terms and conditions and our Privacy Policy when you submit or complete any form provided by you to City Clinic.

Cancellation and No Show Policy
Should you need to cancel or reschedule your appointment, we require a minimum of 3 business hours notice prior to your appointment to allow us to offer your time to another patient. Pilates Studio cancellations require a minimum of 24 hours notice for private lessons and 7 days notice for class sessions.

Should you cancel or re-schedule an appointment without the required notice you will incur a charge of 50% of the consultation fee. A no-show for an appointment is charged 100% of the consultation fee. All unpaid accounts are charged an additional $15.00 + GST per month administration fee while ever an account remains unpaid.

Treatment Schedule
The treatment schedule recommended by your health professional is designed to give you the best possible results. Missed or rescheduled appointments may undermine the efficacy of your treatment. If your treating health professional is ever ill or not available for any reason we will always endeavour to have a colleague available to treat you.

All City Clinic health professionals have your patient file available to them in such circumstances to help ensure patients continue to achieve the best possible outcomes. If we are unable to have a colleague available we will call you, prior your arrival at City Clinic, to reschedule.

Payment Policy
Fees are payable at the time of consultation and can be made by cash, cheque, credit card, EFTPOS, PayPal or HICAPS. We do not invoice.

Waiting Time
Despite our best intentions, we sometimes run late! This is usually because someone has needed extended attention. Be assured that when your turn comes we will not rush to catch up, but will give your problem the time it deserves. Please feel free to ring us prior to your appointment to find out if we are running behind. In the eventuality that we are running well over time we will contact you prior your appointment.

Pilates and Gymnasium Studio
Towels must be used on all benches during exercise. Wipe down equipment, mats and machines after use. Exercise Smart - maintain correct technique for the duration of the exercise. If unsure about a specific exercise, stretch, or use of equipment, ask a staff member before attempting. Shoes must be worn at all times except when attending Pilates. Pilates clients must bring and wear clean socks for their sessions. Both late cancellations and no shows for Pilates will be charged 100% of the fee.

Security
City Clinic is committed to providing the highest level of security possible including preventative measures with staff to ensure your file is not compromised.

Your patient file is created in a secured database from City Clinic owned forms submitted by you either at our centre or via a secured form on our website. Your Patient Record (medical history) is created by your treating City Clinic healthcare worker at your first appointment and must be accurately maintained by treating healthcare workers following each visit to City Clinic. Access to your patient file is via an audited two step login process with regular prompted changes in passwords at both levels.

City Clinic healthcare workers do not have access to any patient's contact information including street addresses, emails and phone numbers and are bound by agreement with City Clinic not to solicit this information directly from patients. All contact with patients, outside your appointments, is co-ordinated via reception adding an additional layer of security over your patient file.

Soliciting, collecting, copying or downloading your contact information or any part of your patient record for the purposes of removing it from City Clinic by any person, including management, employees, sub-contractors and locums, without your written authority to do so, is a breach of the Privacy Act 1998, the Commonwealth Copyright Act as it pertains to health records, our Privacy Policy with you and all City Clinic employment / contractor agreements written or otherwise agreed.

All City Clinic healthcare workers are also bound by enforceable restrictive covenants while working at City Clinic and for 12 months following termination of their agreements with City Clinic unless they have otherwise agreed a variation of their agreements with the owners of City Clinic. These covenants include City Clinic healthcare workers not practising within a radius of 2 klms of City Clinic and not to solicit or persuade any patient who has obtained medical or health services at City Clinic to cease obtaining medical or health services at City Clinic.

Change of Address
Please advise reception of any change of address, contact numbers or email address or complete our Patient data change form.

Definitions:
Patient File - means the whole of the information including contact information, medical records, attachments and any other information relative to the patient.
Patient Record - means the medical record or history of the patient collected at your 1st appointment by a healthcare professional and history and all information added to the record by treating healthcare professionals.

You acknowledge your understanding of our Privacy Policy when you submit or complete any form provided to you via City Clinic's websites or any persons employed by City Clinic.

Our Privacy Policy ensures your patient file is maintained with the greatest care for security, accuracy and privacy and that it complies with all current State and Federal Privacy Legislation.

We will not sell or otherwise provide your personal information to a third party or make any other use of personal information for any purpose which is not specifically allowed under this Policy or is not incidental to the normal use of our services.

Your patient file and any information contained in your patient file, including: contact information, the patient record (medical history) and any relevant attachments cannot be removed from City Clinic secured servers to any other location without written authority, provided by you, to Robab Pty Ltd (Licensor TM City Clinic).

After paying your account we do not retain any credit / debit card or other payment method information.

Your patient file is created by our reception staff from information you provide on City Clinic owned forms prior to (online) or when you attend your first appointment. As an additional security measure, after your patient file is created on our computer system all contact information is greyed out providing access only to your name and date of birth. Your patient record (medical record or history contained within the patient file) is required to be created and maintained on our computer system by your treating healthcare professional(s) incorporating all appropriate information to provide a full understanding of your medical history relevant to a medical or health practitioner (example referring doctors, specialists, other healthcare workers).

These records and specific attachments (consent forms, doctor or other health professional referrals, imaging and diagnostic reports etc.), your name and date of birth are the only items in your patient file available to healthcare professionals at City Clinic. Whilst these parts of your file are only available to healthcare professionals they are jointly owned by the health professionals who create or contribute to the record and City Clinic and must be maintained for a period of seven years from your last visit to City Clinic. However regardless of any ownership in part or whole of the patient record none of this information nor any contact information can be removed from City Clinic by any person without your written authority or a court order provided to the owners of City Clinic.

Health Records and Information Privacy Act 2002 entitles you to request access to your patient record. Under the Act City Clinic is required to see evidence of your or your agents’ identity and a written authority from you to copy any information contained in your patient record before providing it to any person or organisation authorised by you. City Clinic is entitled to charge a reasonable administration fee for providing a copy of any requested information.

Soliciting or in any other way obtaining, copying or downloading your contact information for the purposes of removing it from City Clinic or removing any other part of your patient file by any person, including management, employees and sub-contractors or any other person provided lawful access to City Clinic premises, without your written authority to do so, is a breach of the Privacy Act 1998, our Privacy Policy with you and all City Clinic employment / contractor agreements written or otherwise agreed. All management, employees, locums, healthcare contractors and any other person, provided lawful access to City Clinic, are automatically bound by this Privacy Policy when they work for or enter City Clinic premises.

All City Clinic practitioners are bound by enforceable restrictive covenants while working at City Clinic and for 12 months following termination of their agreements with City Clinic unless they have otherwise agreed a variation of their agreements with the owners of City Clinic. These covenants include City Clinic healthcare professionals not practicing within a radius of 2 klms of any City Clinic location and not to solicit or persuade any patient who has obtained medical or health services at City Clinic to follow them to another location or cease obtaining medical or health services at City Clinic.

Under the guidelines of the Office of the Australian Information Commissioner (OAIC) City Clinic is required to notify you immediately if there is any breach or suspected breach of your patient file or any part of your patient file. As of March 2014 notification of any breach is mandatory and at the discretion of the Privacy Commissioner City Clinic and or persons responsible for any breach may be liable to heavy fines by the OAIC (Privacy Amendment - Enhancing Privacy Protection Bill 2012). In the unlikely event a breach or suspected breach occurs notification to you may be by SMS, e-mail or post.

All City Clinic owned websites and centres provide forms that may ask you to provide contact information and other information so that we may deal with your health related requirements, queries, online appointments or requests to receive information that is relevant to you. Some non-personal information may be collected, via these forms, to assist City Clinic manage patient expectations. This information is kept anonymously and with no cross reference to you.

We may use contact information you provide to SMS or e-mail appointment reminders to help prevent you missing appointments.

We may also use your contact details to provide information about City Clinic such as notification of new services, updates, birthday or welcome cards, invite feedback on our services, newsletters, conduct surveys on possible future initiatives or request a vote for City Clinic in the Annual Sydney or Telstra Business Awards.

If you wish to opt out of receiving SMS, e-mail appointment reminders or any other communications please check the appropriate boxes on the patient information form prior your first appointment. If you have completed the form and not checked the related box you can always opt out by informing reception via our contact us form (See drop down in 'Online Forms' at cityclinic.com.au).

If there are changes to your contact information please visit and complete our 'Patient Data Change Form' (See drop down in 'Online Forms' at cityclinic.com.au).

If you have any questions about this Privacy Policy or information provided on our websites, please feel free to contact us.

References:
OAIC Data Breach Notification April 2012
OAIC Reasonable steps’ to protect personal information April 2013
OAIC Australian Privacy Principles and Information Privacy Principles April 2013
OAIC Australian Privacy Principles and National Privacy Principles April 2013
OAIC Guide to information security summary April 2013
Health Records and Information Privacy Act 2002
Privacy Amendment (Enhancing Privacy Protection) Bill 2012

©2013 City Clinic®. All Rights Reserved.
Robab Pty Ltd (Licensor TM City Clinic®).