Signing example
Sign a physiotherapy consent form online
A physiotherapy consent form has to capture the patient's answers to the safety questions before any needle goes in, and show the physiotherapist read those answers before treating. In this two page consent for low back pain with dry needling, the patient marks one of five screening questions with an X and signs, and the physio countersigns twenty minutes later.
The document, with its fields
The pages as a signer sees them, with the signature, name, title and date fields placed where each party has to complete them.
Physiotherapy Treatment Consent
1. Patient and physiotherapist
| Patient | Joel Ashworth, date of birth 21 May 1983, client number NSP-6620 |
|---|---|
| Physiotherapist | Kieran Holloway, physiotherapist, registered with the Physiotherapy Board of Australia |
| Presenting problem | Right sided low back pain for three weeks after lifting a kayak, no leg symptoms |
2. Treatments that may be used
| Treatment | What it involves |
|---|---|
| Exercise therapy | Graded movement and strengthening exercises, done in the clinic and at home |
| Manual therapy | Hands on mobilisation of the spine and soft tissue massage. No high velocity manipulation without separate verbal consent at the time |
| Dry needling | Fine, single use, sterile needles inserted into tight muscle in the lower back and buttock, left for up to ten minutes |
| Heat and taping | Heat packs and rigid or elastic tape to support movement |
3. Risks of dry needling
Most people feel a brief cramp or ache when a needle is placed, and soreness for a day or two afterwards. Less common effects are bruising, feeling faint and temporary tiredness. Rare but serious risks include infection and, for needles placed over the chest wall, a punctured lung, which is why needles are not placed over the chest in this treatment.
4. Safety questions
Some conditions make dry needling or manual therapy unsafe. The patient types an X in the box beside any statement that is true, in their own signing session. An X means yes. An empty box means no. Any X is discussed with the physiotherapist before the treatment it affects.
| Yes | Statement |
|---|---|
| I take blood thinning medicine, such as warfarin or apixaban, or I bleed or bruise easily. | |
| I am, or may be, pregnant. | |
| I have a fear of needles, or have fainted during an injection or blood test. | |
| I have diabetes, a weakened immune system or an infection near the area to be treated. | |
| I have a pacemaker or other implanted device, a metal allergy, or recent surgery near the area to be treated. |
5. Fees and appointments
| Service | Fee |
|---|---|
| Initial assessment and treatment, 45 minutes | $120.00 |
| Follow up treatment, 30 minutes | $95.00 |
| Dry needling within a consultation | No extra charge |
Fees are paid at each visit. The clinic claims private health insurance rebates on the spot. Please give 24 hours' notice to cancel; a late cancellation may be charged at $40.00.
6. Your rights
- You may ask questions about any treatment before it starts, and you may stop or refuse any treatment at any time, including partway through a session.
- You may ask for a chaperone or support person to be present.
- The physiotherapist explains which areas need to be uncovered and why, and uses towels to cover everything else.
- Your notes are kept for at least seven years under the Australian Privacy Principles, and you may ask for a copy.
7. Patient's consent
I have answered the safety questions on page 1 truthfully. The proposed treatments, including dry needling, and their risks have been explained to me and I have been able to ask questions. I consent to physiotherapy assessment and treatment as described, and I understand I can withdraw this consent at any time.
8. Physiotherapist's statement
I have reviewed the patient's answers to the safety questions before treatment, explained the treatments and the material risks, and I am satisfied the patient understands them.
Who signs what
- Joel Ashworth, patient
- Five safety questions on page 1, an X beside any that are true · Signature and stamped date on page 2 · Email link
- Kieran Holloway, physiotherapist
- Signature block on page 2: Name, Title and a stamped Date · Email link
The signing journey
Step 1
Five optional boxes
Each checkbox's Required switch is off, so an empty box is a valid answer. That is what makes a no possible on a yes or no checklist.
Step 2
The patient answers first
Sign in order is on. Joel types an X beside the needle fear question only, leaves the other four empty and signs page 2.
Step 3
The physio reads, then signs
Kieran's invitation arrives when Joel's signature lands. He reviews the answer before signing, and in this run signed twenty minutes after the patient.
Step 4
Both times on the certificate
The certificate shows Joel signing at 10:27:21 UTC and Kieran at 10:47:41 UTC, with the invitation to Kieran between them in the event log.
Every field, and who fills it
Joel Ashworth sees five statements in a table on page 1, about blood thinners, pregnancy, needle fear or fainting, diabetes or infection, and implants or metal allergy. He types an X in the Yes column beside the third and leaves the rest empty. On page 2 he draws his signature under the patient's consent and the date is stamped. Kieran Holloway's block sits beside it, headed Physiotherapist, with his name, the title he types and a stamped date. Fees of $120 and $95 are printed.
How to adapt this envelope
A clinic that does not offer dry needling drops the needling rows and keeps the manual therapy questions. A pelvic health service adds questions specific to internal examination and a statement about a chaperone, each as its own box. For a patient under 18, a parent becomes the first recipient and signs on their behalf, with the patient's name printed in the table.
What makes this valid in Australia
The Electronic Transactions Act 1999 recognises an electronic signature that identifies the signer and shows intention by a reliable method. Physiotherapists are registered with the Physiotherapy Board of Australia, whose code of conduct expects informed consent before treatment, which national guidance describes as a conversation about options and material risks. The signed form records that conversation and the patient's answers.
What makes this signing flow work
An X means yes, and says so
Because a checkbox prints an X for any value, the form spells out above the table that an X means yes and an empty box means no. The finished page reads correctly to anyone who opens it, without knowing how the fields were set up.
The answers come before the countersignature
The physio's statement on page 2 says he reviewed the answers before treatment. With the order on he could not sign until Joel had answered, and the gap between their two signing times shows the review happened.
One yes, handled at the clinic
Joel marked that he has fainted during an injection. The form says any X is discussed before the treatment it affects, so the record shows the clinic knew before needling, which is when it matters.
Questions people ask
Can a checkbox record a no answer?
Only if it is optional. A required checkbox must have a value before the patient can finish, which would force an X on every question. Here each of the five was made optional in the editor, so leaving a box empty is allowed and means no, as the form says.
Why did the physio sign twenty minutes after the patient?
His invitation only arrived once the patient had signed, and he read the answers before countersigning. The certificate records both signing times to the second, so the gap between them is visible to anyone who opens the certificate, without anyone having to vouch for it.
Is dry needling consent different from general physio consent?
It carries its own risks, such as fainting, bruising and, near the chest wall, a punctured lung, and its own screening questions. This form names dry needling separately in the treatment table and in clause 3 so the patient's consent clearly covers it.
Can the patient complete this in the waiting room?
Yes, on a phone. The link opens without an account, and on a narrow screen the five boxes move into a panel above the document. Many clinics send it with the booking confirmation instead, so the answers are in before the first appointment.
Is a physiotherapy consent valid when signed electronically?
In Australia, yes, where the method identifies the patient and shows intention, which the Electronic Transactions Act 1999 accepts. The certificate keeps the verification method, IP address and consent time for each signer, and the certified PDF cannot be altered afterwards.
What if the patient declines the form?
The envelope moves to declined and the clinic is emailed with any reason typed. The physio is never invited. The patient can still be assessed, and treatments that need consent, such as dry needling, wait until a new form is signed.
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