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Precise Rehab consent form
精确康复同意书
Datas collected will be used for medical or among school staff only.
收集的数据将仅用于医疗或学校教职工
.
Mobile
State the area/areas that your child is currently having problem/s at:
请问说明您的孩子目前遇到问题/ 不舒服的地方
Choose from the list
Obesity 肥胖
Lower back pain 腰痛
Sports injury 运动损伤
Muscle strain 肌肉拉伤
Neck pain 颈部疼痛
Shoulder injury 肩伤
Others 其他
Closest branch location
最近的分行
Please select (请选择)
Hartamas
Bangsar
Shah Alam
Bukit Jalil
Titiwangsa
Taman Sea, PJ
Georgetown, Penang
None of the above
Physiotherapy Service Consent Form
I hereby declare that my child is free from any serious medical conditions or issues*:
*1.Surgical incision or Open Wound
2. Hypersensitive Skin
3. Healing Fracture
4. Acute Inflammation (Rheumatoid Arthritis)
5. Cancer or Tumor
6. Osteoporosis (Advance)
7. Diabetes (Advance)
8. Deep Vein Thrombosis / Varicose Vein or any musculoskeletal injuries
9. Pregnant
10. Taking blood thinning (or heamophilia disorder)
11. Using long-term steroids
12. Immunosuppressant medication or have an implanted device.
I consent to the proceedings of evaluation and treatment as deemed appropriate, and I have been made aware of the risks and benefits associated with treatment or rehab services. I agree to release PRECISE REHAB, and its associates from all damages that may result from all respected treatment or rehab services.
物理治疗服务同意书
我特此声明我的孩子没有任何严重的健康状况或问题*:
*1. 手术切口
或
开放性伤
2. 过敏性皮肤
3. 骨折愈合
4. 急性炎症(类风湿性关节炎
5. 癌症或肿瘤
6. 骨质疏松症(晚期
7. 糖尿病(晚期
8. 深静脉血栓形成/静脉曲张或任何肌肉骨骼损伤
9. 怀孕
10. 血液稀释(或血友病)
11. 长期使用类固醇
12. 免疫抑制药物或植入装置。
我同意适当的评估和治疗程序,并且我已了解与治疗或康复服务相关的风险和益处。我同意免除 PRECISE REHAB 及其相关人员因所有相关的治疗或康复服务而造成的所有损害。
身体接触和暴露治疗区域的必要性 (手, 腿或脊椎)
Necessity of physical contact and exposure of treatment area (hand, leg or spine)
授权发布所有必要信息
Authorising the release of all necessary information
我想要跟进疗程/复诊
I would like a follow-up session
Register me!