Illegal Practice Reporting Form

Last name

First name

Name of organization

Street and number

City

Postal code

Phone number

Website

Last name

First name

Member number

Street and number

City

Postal code

Email*

Phone number

Choose the applicable activities (select all that apply)

Assessment of neuromusculoskeletal function in a person with a physical disability or impairment

Functional assessment of a person when required by law

Insertion of an instrument or finger into the body past the labia majora or anal verge

Insertion of an instrument into the body past the pharynx or nasal vestibule

Use of invasive forms of energy

Wound-related treatment

Decision-making on the use of restraint measures

Use of needles under the skin to reduce inflammation, in addition to other means

Performance of spinal and joint manipulations

Choose the applicable titles (select all that apply)

Physiothérapeute, pht

Physiotherapist, P.T.

Physical therapist

Thérapeute en réadaptation physique, T.R.P.

Physical rehabilitation therapist, PRT

Technologue en physiothérapie, T. phys.

Physiotherapy technologist, Phys. T.

Briefly summarize why you are filing a report*

Please add any relevant proof here

(business card, advertisement, website, Facebook page, invoice for services, etc.)

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