Roots Health Clinic – Terms & Conditions and Informed Consent

This section is written in the first person (“I”) so it can function as a separate informed consent form if needed.

By proceeding with care at Roots Health Clinic, I acknowledge and agree to the following:

Understanding the information
I have read and understood all the above contained in this form and any accompanying explanations about the nature of the Services at Roots.

Consent to assessment and therapy
I declare that I am giving consent for:

the initial history taking,

physical examination, and

therapy/treatment
if the practitioner justifies it to be appropriate, within the scope of chiropractic, physiotherapy, massage, functional movement, or hypnotherapy as offered at Roots.

Risks of manual and physical therapy
I acknowledge that I understand the rare risks associated with manual therapy. These uncommon risks associated with my proposed care include (although are not limited to):
muscle and joint soreness or strains, tiredness, nausea and dizziness, fractures, disc injuries, strokes (or stroke‑like episodes), and an exacerbation and/or aggravation of my underlying condition.

Duty to ask questions
I understand that it is my duty to ask questions about the nature, extent, and purpose of the proposed management and to allow myself sufficient time to make a decision about giving consent for care to proceed.

Attendance, care and results
I acknowledge that I am aware of and understand that potential risks and results are dependent on my attendance, my level of participation, and the care provided. I understand that no specific result or cure can be guaranteed.

Limits of what a practitioner can foresee
I do not expect the practitioner to be able to anticipate all potential risks and complications associated with the proposed care.

No healing or cure of disease
I understand that chiropractic, physiotherapy, massage, functional movement, hypnotherapy and other manual therapies do not heal or cure any disease. I understand that:

These therapies are intended to support my body’s function, comfort, and recovery,

They are not offered as a cure for any medical condition or disease, and

Roots Health Clinic is not a medical facility and does not diagnose or medically treat disease.

Rekonvalescence / rekondice / regenerace
I understand that the services provided are intended to support rekonvalescence (convalescence), rekondice and regenerace (reconditioning and regeneration). This means supportive care for recovery, improved function, and well‑being, rather than medical treatment or cure of disease.

Right to withdraw consent
I understand that I can withdraw my consent at any time, and that I may:

stop or pause a session, or

refuse any technique or recommendation
at any time, without needing to give a reason. I will communicate my concerns to the practitioner.

Scope of consent
I hereby give my consent to the performance of the proposed treatment by the clinician and/or any other clinician working in this clinic, provided they are acting within their professional scope and have explained the proposed treatment to me.

Disclosure of health information
I confirm that I have informed the practitioner about any:

serious medical diagnoses,

current medications and treatments,

previous surgeries, major injuries, or conditions, and

pregnancy, suspected pregnancy, or breastfeeding (if applicable).

I understand that it is my responsibility to keep the practitioner updated about changes in my health.

Freedom to seek medical advice
I understand that I am free to seek medical advice at any time and have been advised to consult my medical doctor or specialist for diagnosis, testing, or medical management of any disease, and for any symptom that worries me.

By signing (or by proceeding with my appointment), I confirm that I have read, understood, and voluntarily agree to the above.