Consent Forms

You will be sent a copy of the appropriate consent form to complete prior to your initial appointment with Katy Folley Wellness. This must be completed before the appointment starts

Pelvic floor evaluation and treatment

Consent form

I acknowledge and understand that I have been referred for evaluation and treatment of pelvic floor dysfunction.

Pelvic floor dysfunction includes but is not limited to, urinary and faecal incontinence, difficulty with bladder, bowel or sexual functions, painful scars after childbirth or surgery, persistent sacroiliac or low back pain or pelvic pain conditions.

I understand that I will have the opportunity to revoke my consent at any point before or during the examination/treatment.

I understand that I may have a person of choice accompany me during the evaluation, and that the examination will occur in a clean, private, and secure area.

I understand that I will be required to disrobe for the exam and that appropriate draping and coverings will be provided.

I understand that the examination is performed by observing, palpating (assessing through touch) or inserting a gloved finger into the perianal region including the vagina and/or rectum. The evaluation will assess skin condition, reflexes, muscle tone, length, strength and endurance, scar mobility and function of the pelvic floor region.

Treatments may include but is not limited to: observation, palpation, use of vaginal or rectal sensors for biofeedback or electrical stimulation, stretching and strengthening exercises, soft tissue and joint mobilisation, and educational instruction.

Potential risks

I may experience an increase in my current level of pain or discomfort, minor bleeding or infection. These effects are usually temporary. If they do not subside in 1-3 days, I agree to contact Katy Folley on 07859 216922.

Potential Benefits

I may experience an improvement in my symptoms, and an increase in my ability to perform daily activities. I may experience increased strength, awareness and endurance of the muscles. I may experience reduced pain and discomfort. I should gain a greater knowledge about managing my condition.

By signing below I acknowledge that I have read and understood the above information, and have been given the opportunity to ask any questions about the information and have had these answered to my satisfaction.

Name:

Signature:

Date:

Physiotherapy Consent Form

At Katy Folley Wellness, our physiotherapy services focus on improving function, and reducing pain through a combination of hands-on techniques, exercise therapy, and holistic approaches tailored to your needs.

Treatment Plan

Your physiotherapy care may include:

Manual Therapy (joint mobilization, soft tissue release, scar massage)
Therapeutic Exercise (rehabilitation, strength, flexibility training)
Postural & Movement Education
Visceral & Scar Mobilization
Electrotherapy or Other Modalities (as needed)
Home Exercise Programs & Self-Management Strategies

Potential Benefits

Pain relief and improved mobility
Increased strength, flexibility, and function
Faster recovery from injury or surgery
Prevention of future injuries and dysfunction

Potential Risks

While physiotherapy is generally safe, potential risks may include:

Temporary soreness, discomfort, or mild bruising
Aggravation of existing conditions if not followed correctly
Unexpected response to treatment, depending on individual conditions

Patient Responsibilities

To ensure the best outcomes, you agree to:

Communicate any discomfort or concerns during treatment.
Follow the recommended treatment plan and home exercises.
Inform your physiotherapist of any health changes or medical conditions.

I have the right to withdraw my consent at any time.

Patient Consent

I consent to receive physiotherapy treatment at Katy Folley Wellness and understand that I can discontinue treatment at any time.

Patient Name:

Patient Signature:

Date: