Consent to Treatment

Name*

Date of Birth (DDMMYYYY)*

Gender*

Male

Female

Other

Email*

Contact Number*

Address*

Postal Code*

I voluntarily consent to Homeopathic treatment provided by R S Saini, Shveta Saini (Homeopath) and associated Homeopaths, interns and clinicians.

- I am aware that the practice of medicine (be it homeopathy or western medicine) is a science and I acknowledge that no guarantees have been made as to the result of treatment or examinations.

- I agree to participate in assessment and treatments given by the treating provider. I understand that it will involve my active participation in treatment and will comply with the provider’s recommendation to enhance my recovery.

- I understand that the assessment and treatment services I undergo may be administered by the treating provider, and by the support staff under the supervision of the treating provider.

- I understand that Homeopathic medicine is not covered by the provincial government, though may be covered by private and extended insurance plans. Homeopathic medicine may also be tax deductible.

- I understand that the complete fees, taxes and remedy charges have been clarified to me.

- Payment is due at the end of each visit as the clinic does not bill insurance companies directly. Nor do we claim responsibility of collection for insurance claims or for the negotiation of a disputed claim.*

Cash, Interac, Visa, and Mastercard are acceptable methods of payment.

Credit card number is required at the time of registration to be saved securely in the file.

- Twenty-four hour notice is required when cancelling or changing an appointment. Otherwise, I understand that I will be charged $30 for the missed appointment fee.

- If I am late for an appointment, I will be charged the full appointment fee though the appointment will consist of the time remaining.

- I understand that R S Saini & Shveta Saini (Homeopath) and associates will keep a record of my personal health information and of the services provided to me. This record will be kept confidential and will not be released to others unless so directed by myself or unless required by law.

- I understand that homeopathic medicine can be employed in conjunction with other forms of therapy and need not be considered exclusively beneficial. The homeopathic treatment received does not substitute or replace routine medical visits, tests, or other medicines prescribed by the family physician or other medical doctor.

- I recognise that even the gentlest forms of treatment potentially can have their risks and complications. The risks associated with Homeopathic medicines include, but are not limited to, aggravation of pre-existing symptoms, a relapse of symptoms, temporary increase in the intensity of symptoms, and the temporary development of new symptoms, until more permanent relief is attained. These temporary symptoms will vanish on their own with continued homeopathic treatment.

With this knowledge, I voluntarily consent to Homeopathic care and I intend for this consent form to cover my entire course of treatment. I understand that I am free to withdraw my consent at any time.

Date*

CONSENT TO TREATMENT

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