Informed Consent / Terms and Conditions / Consent Statement

Redlex Fysio & Massage: • Address: Zamenhofstraat 108-305, 1022 AG, Amsterdam (North)

• Website: www.redlexfysio.nl
• Email: redlexfysio@gmail.com
• Phone: 0610212647

Therapist: Your treating physiotherapist is RJC Valk.
He is a registered (KNGF) and certified (BIG: 59925093804) physiotherapist.
AGB (RJC Valk): 04245438.
AGB practice: 04047384.

Massage Therapist: Your treating massage therapist is A. Valk Matteman

Dear patient, You are about to undergo treatment at Redlex Fysiotherapie & Massage in Amsterdam Noord.
Below you will find the details and terms and conditions you must agree to before the treatment actually takes place.

Available Treatments:

• Physiotherapy
• Dry Needling
• Electrical Dry Needling (E-Stim)
• Cupping Massage Therapy
• IASTM (Instrument Assisted Soft Tissue Mobilisation)
• Ultrasound
• Shockwave Therapy
• Medical Taping
• Triggerpointmassage
• Deep Tissue Massage
• Connective Tissue Massage
• Exercise Therapy
• Hot-Stone Massage
• Stress Relief Relax Massage
• Pregnancy Massage

The above-mentioned treatments/interventions may be part of your physiotherapy treatment plan,
which will be discussed with you during your intake. Below, you will be informed about the contraindications and risks of each treatment.

Notice of Risk

As with any physiotherapeutic treatment or massage therapy, unintended complications may occur.
Although rare, these may include redness, bruising, swelling, stiffness, increased pain, or inflammation.
These symptoms are typically temporary (lasting 1–2 weeks).

Severe complications associated with mobilizations, dry needling, e-stim, IASTM, and shockwave therapy are extremely rare but can include:
bone fractures, dislocations, bleeding, pulmonary embolism, muscle tears, herniations, paralysis, or a collapsed lung (pneumothorax).

The Physiotherapists and Massage Therapists of Redlex Fysiotherapie & Massage are not liable for any physical injury resulting from treatments,
as you have been informed of these possible but rare complications. This risk has been discussed with you in advance and has been documented. *

I am aware that possible complications may arise and accept that Redlex Fysiotherapie/Massage and its therapists cannot be held liable for any complications that may unexpectedly arise.

I give my consent for the following treatment methods:

Our standard Physiotherapy treatment includes: Medical Taping, exercise therapy, mobilizations, and massage techniques (e.g., Deep Tissue, Trigger Point & Connective Tissue).

Please note: Additional therapies such as Cupping, Dry Needling, E-stim, IASTM, Ultrasound, and Shockwave are not included by default. If you wish to make use of these methods, please select them below in addition to 'Physiotherapy'. We cannot perform these additional therapies without your explicit consent.

Are you here for Physiotherapy? Check the 'Physiotherapy' box and also select the additional techniques (such as Cupping, Shockwave, etc.) that we may use in your treatment plan.
Are you here specifically for a Massage (non-physio)? Please select only the specific massage type you have booked (e.g., Deep Tissue or Hot Stone).

Note: Dry Needling and E-stim will be addressed separately later in this form. *

Consent Dry Needling | Elektrische Dry Needling (E-Stim):
I, the undersigned, hereby give my voluntary consent for the use of dry needling and/or E-stim (electrical dry needling) therapy.
Dry needling and/or E-stim therapy is a (para)medical treatment involving the insertion of special, sterilized,
fine needles into specific muscle areas (E-stim is dry needling combined with electrical stimulation on the needles at approximately 5 volts)
with the aim of relieving pain and improving mobility and blood flow. I have been informed that complications may occur;
These may include:

- Infections
- Bleeding/bruising
- Temporary increase in pain due to nerve stimulation
- Fatigue/weakness
- Fainting
- Vegetative symptoms such as sweating and nausea
- Worsening of symptoms for some time
- Pneumothorax or another organ that is punctured

I further declare that none of the following conditions apply:
- Pregnancy
- Pacemaker, ICD, or other electrical implanted devices
- Cosmetic implants (Buttocks, Breasts)
- Anticoagulant medication (Blood thinners)
- Bleeding problems (Abnormal bleeding tendency)
- Local infections and/or systemic infections (Hepatitis B, hepatitis C and HIV)
- Joint surgery Artificial heart valve
- Bacterial endocarditis (Heart muscle or pericardium inflammation)
- Reduced immune system
- Gland resection / edema
- Tumor Skin or metal allergy
- Fear of needles
- Unfavorable reaction after using (injection) needles
- Rapid tendency to faint
- Diabetes

Redlex Fysio/Massage and its therapists are not liable for any physical injury resulting from the treatments. This risk has been discussed and documented with you in advance. *

Yes, I agree to Dry Needling and/or E-stim and I am aware that possible complications may occur and accept that Redlex Fysio/Massage and its therapists cannot be held liable for any complications that may unexpectedly arise.

No, I do not agree to dry needling and/or e-stim, because I do not want to undergo this treatment.

Privacy and Terms and Conditions :
By signing, you agree to the use of your personal data (name, address, citizen service number, email address, telephone number) for medical purposes
and declare that youhave read and understood the general terms and conditions, house rules, and privacy rules .

Consent for Physical Examination:
By signing, you consent to the necessary physical contact during the diagnostic and therapeutic process.
You will be explained beforehand why and where contact is necessary.

Consent to use your data for LDF
We would like to ask your permission to use some information about you and your treatment and to share this information with the national physiotherapy database (LDF).
This is an initiative of our professional association for physiotherapists, the KNGF (Royal Dutch Physiotherapy Association). Treatment data is collected in this database and used for quality assurance,
research, and the improvement of physiotherapy care. Your data will be handled with care and used only for medical purposes.
The following information about you and your treatment will be shared: Gender, date of birth, postal code, patient ID from your health insurance, treatment details (your complaint),
type of treatment, and the results. Your name and contact details such as email address, telephone number, and house number will not be shared to protect your privacy.

Consent to use QDNA (Satisfaction Survey)
We would like to ask your permission to use some information about you, which will be shared with QDNA.
This is an independent party that conducts mandatory satisfaction surveys for physiotherapy practices to ensure quality.
After your treatment, you will automatically receive an email inviting you to complete a survey about your experience with the practice and the treatment.

Data Collection
When you come for treatment at Redlex Fysio & Massage, we ask you to provide personal data.
This data is used to provide our services. We process, among other things, your name, gender, address, place of residence
, date of birth, telephone number, citizen service number (BSN), telephone number(s), general practitioner, health insurer/policy number details, your email address and identification information
, and any other information related to or relevant to your physiotherapy treatment. We store this data in our electronic patient file where
we record and monitor your treatment progress. We do not collect or use information for purposes other than those described in this
privacy policy unless we have obtained your prior consent.

How do we handle your data?
We ensure appropriate security of your data. This means that only your therapist (or their representative) can access the data.
Furthermore, we only use the data as stated in this privacy policy.

Important to know: we do not give or sell our clients' personal data to third parties so that they can use that data for marketing activities, for example.

Disclosure to third parties:
Redlex Fysio & Massage collaborates with partners, for example, for the administration and invoicing of treatments.
Therefore, we may disclose your personal data to these partners.
Our partners are obligated to handle your personal data with care.
They may not use your data for anything other than the purpose for which it was provided to them.

Customer Experience Survey – QDNA (name and email address only).
LDF (National Physiotherapy Database).
To mail you information about the practice, including holidays, etc.
Providing financial administration.
Your health insurer may request certain (treatment) data.
Other healthcare providers, such as your doctor or GP. This is necessary to ensure the best possible care for you.
We only share your data with other healthcare providers with your consent.
Legal requirements may breach the healthcare provider's duty of confidentiality if there is a serious risk to your health or that of a third party.

Transferring your file:
If you choose a different physiotherapist, we will transfer your file after your approval.
We will do this as soon as possible after your request. We will transfer it in person or via secure email transfer.
You will not receive the original file, but you do have the right to inspect it.

Would you like to review or make changes?
All visitors to Redlex Fysio & Massage have the option to review, change, or delete all personal information provided to us at any time.

Rights
In this privacy statement we must inform you of your right to complain to the supervisory authority (the Dutch Data Protection Authority) and the right to access all personal information that has been provided to us at any time.

Security, Modifications, and Unsubscribes:
Redlex Fysio & Massage takes the protection of your data seriously and has taken appropriate measures to prevent loss, unauthorized access, misuse, unwanted disclosure, and unauthorized modification.
In addition to the physiotherapist treating you, a limited number of other people in the practice also have access to your data, including observers hired in certain cases.
All these people are bound by a duty of confidentiality.

We also have a data breach reporting obligation. If an incident occurs in which your data may have fallen into the hands of unauthorized persons,
we are obligated to report this to the Dutch Data Protection Authority, and we will also inform those involved.

I agree to the terms and conditions and the privacy policy

I agree to the recording of my data for the electronic patient file

I give consent for a physical examination

I agree to the use of my data for the LDF

I agree to the use of my data by QDNA

I do NOT give permission for the use of my data for the LDF

I do NOT give permission for my data to be used by QDNA

Name: *

Surname: *

Date of Birth: *

Adress and Housenumber: *

Postcode *

Phone Number: *

Email: *

Please mention any medical conditions we should take into account during your treatment.

Examples include: Diabetes, anemia, pregnancy, high or low blood pressure, dizziness, use of blood thinners,
heart conditions, kidney problems, fear of needles, easy bruising, skin conditions, Hepatitis A-B-C, leukemia, etc.

* = Invoer verplicht