If you are booking an appointment, please read the following declaration carefully and ask any questions you may have prior to your initial consultation with your practitioner. Please advise the practitioner on booking that you have read the Client Consent Form.
In agreeing to the following, you declare that:
- You understand that the form of health care provided at this clinic is based on Naturopathic Medicine and other supportive principles and practices. Treatment modalities include:
Nutrition and Herbalism
- You recognize that even the gentlest therapies may cause complications in certain physiological conditions such as pregnancy, lactation, very young children, very elderly patients, those on multiple medications, or those with specific diseases such as heart, liver, kidney or diabetes.
- All information you have provided to your practitioner, Elizabeth d’Avigdor, about your current health condition, both in your Client Intake Form and during any subsequent consultations, is true and correct to the best of your knowledge.
- You agree to inform your practitioner, Elizabeth d’Avigdor, of any changes to your current medical/health condition, including any new medications, herbs, vitamins, supplements etc you are taking, any new injuries or diagnosed/undiagnosed medical conditions.
- If you are female, you agree to inform your practitioner immediately if you fall pregnant, suspect that you are pregnant, plan to fall pregnant or if you are breastfeeding.
- You understand that a health record will be kept of the information disclosed in your consultations and the treatments provided to you. This health record will be kept confidential and will not be released to any other person without your written consent, unless required by law.
- You can look at your health record at any time and can request a copy of it as required.
- Your health record may be used for research and treatment purposes, but your identity will be protected and kept confidential.
Information provided and treatments prescribed
In agreeing to the following you declare that:
- You understand that your practitioner (Elizabeth d’Avigdor) holds the following qualifications:
Master of Clinical Science (Comp. Med), Diploma of Nutrition, Diploma of Medical Herbalism, Diploma of Remedial Massage. Member of ATMS and NHA
- You understand that your practitioner, Elizabeth d’Avigdor, is not a medical doctor and that the information provided to you is on no way intended as medical advice, or a substitute to medical counselling and the information supplied should be used in conjunction with the guidance and care of your physician.
- You are at liberty to seek or continue medical care from a physician, or another health care provider.
- No practitioner or employee of Elizabeth d’Avigdor has suggested or advised you to refrain from seeking care from or following the directions of another health care provider.
- You understand your practitioner Elizabeth d’Avigdor will answer all questions and explain all treatments to the best of their ability and, as with any form of treatment, results and lack of side effects cannot be guaranteed.
- You do not expect your practitioner Elizabeth d’Avigdor to be able to anticipate all risks or complications.
- You recognise that despite all precautions on behalf of your practitioner (Elizabeth d’Avigdor), there are risks of side effects/complications/illness occurring as a consequence of the use or misuse of the treatments prescribed by your practitioner (Elizabeth d’Avigdor).
- You expressly assume such risks and waive, relinquish and release any claim which you may have against your practitioner (Elizabeth d’Avigdor ) or their affiliates/employees/contractors as a result of any future injury, illness, liability, loss or damage incurred in connection with, or as a result of your use or misuse of prescribed treatments or advice.
Payment and Cancellation Policy
By signing this form you declare that:
- You are financially liable for all treatment rendered.
- You understand that all consultations must be made by emailing Elizabeth d’Avigdor at firstname.lastname@example.org or via her online booking site
- A minimum of 24 hours from the start of the scheduled appointment is required to cancel the appointment, except in the case of an emergency.
- If cancellations are within 24 hours of the start of the scheduled consultation and are not due to an emergency, you will be charged a cancellation fee of 50% which will be payable prior to scheduling your next appointment.
Declaration and Consent
You declare that:
- You have read and understand the above-stated policies and information.
- You have received a full and complete explanation of the treatment and services that you may receive from Elizabeth d’Avigdor
- You hereby authorize and consent to treatment.
- You intend this consent form to cover the entire course of treatment you receive at Elizabeth d’Avigdor
- You understand you may revoke this authorization for treatment at any time in writing.