Formulaire Téléconsultation - Physio Kin Zen Équilibre

Consent form

Name of therapist: Marilaine Savard, physiotherapist and kinesiologist
Phone number: 514-791-6952

Patient name:

Date of Birth :

Address :

Telephone number (during telerehabilitation):

Telephone number (Emergency services in your area):

Name of contact person to contact in case of emergency:

Phone number:

Relationship to person:

Consent

I authorize MARILAINE SAVARD to carry out the assessments and interventions using telerehabilitation. I acknowledge that at any time, I have the right to refuse telerehabilitation services. No recording of the session will be made to me without my prior consent.

Teleconsultation form

Consent form

Find your balance

Services

About

Physiotherapy treatment

Contact information