RR#1 Ompah, K0H 2J0, ON, Canada
RR#1 Ompah, K0H 2J0, ON, Canada
CONSENT TO TREATMENT
PATIENT'S NAME:__________________________
DATE OF BIRTH (D/M/Y): ______________
Patient's address: __________________________________________________
Postal code:__________________Tel. #: ___________________
Email Address (if available):______________________________
PATIENT'S CONDITION: _________________________________________
_______________________________________________________________
PLEASE READ CAREFULLY AND COMPLETELY:
1. I acknowledge that I am suffering from the condition described
above. I freely and
voluntarily consent to the treatment or procedure described in paragraph
2 (below)
by Helga or Hans Kurt Freitag and other persons of his and/or her choosing.
2. I understand that this treatment consists of some or all of the
following: Electro-
acupuncture Testing, Application of Homeopathic Combinations, Acupuncture,
and Electrical Massaging (applicable to Patients treated at the Natural
Medicine
Centre).
3. (a) I am aware of and have had explained to me that there
are certain risks and
reactions associated with the treatment. The primary risk is detoxification
and
symptoms associated with detoxification. To lessen these symptoms it is
advisable that I drink two litres of water per day during the course of
the
treatment.
(b) I also understand that the side effects associated with homeopathic
treatment
are minimal, and, that other than detoxification and associated symptoms
mentioned above, the treatment should not worsen any health condition I
have.
(c) These risks have been explained to me by Helga or Hans Kurt
Freitag &
associates, and I freely assume them.
4. (a) I understand that the likely benefits of the
treatment are as set out in the
patient information pamphlet that I have received and read (see flyer in
waiting
room or available on the website "HCR Therapy").
(b) I understand that optimal results are only possible if
the series of treatments
is completed. The number of treatments required may vary according to the
individual patient. The treatment is not completed after only one visit/session.
(c) I have received and understood the explanations of the
treatment, any
alternate courses of action and the associated risks and any side effects.
I have
also received understandable answers to any requests I have made for
additional information regarding the treatment.
(d) I acknowledge that no assurance or guarantee can or has been
given that this
treatment or any other treatment will improve my condition. I acknowledge
that
neither Helga nor Hans K. Freitag is licensed under the Regulated Health
Professions Act and I understand that the treatment has not been scientifically
proven to be effective.
5. (a) Prior to the commencement of treatment I agree to
advise Helga Freitag or
Hans K. Freitag which medications I am currently taking, whether I have
a
pacemaker, whether I am pregnant, and any other medical conditions I have.
I
agree to advise Hans K. Freitag or Helga Freitag of any changes in the
medications I am taking and any changes in my health during the course
of the
treatment.
(b) I understand that I have to continue taking the medication(s)
prescribed by
my doctor(s) during the course of the treatment. Should my prescribed
medication(s) need to be adjusted, I must consult my doctor before doing
so.
6. (a) I understand that this treatment is not covered by
OHIP and that the cost
per adult is:
(i) $80.00 for the first test; and
(ii) $50.00 for each additional test.
(b) The cost per child is:
(i) $50.00 for the first test; and
(ii) $30.00 for each additional test.
The cost of the medication is an additional $15.00 or $25.00 per medication
for adults. Total for both medication and initial test is about $300.00,
depending on how much medication you require.
(c) Payments must be rendered upon receiving the remedies by mail
with no
exceptions. Payments may be made by Visa, Mastercard, American Express
or Personal Cheques. Patients will be charged $40.00 CAD for every
cheque
which is returned for insufficient funds and any outstanding accounts will
be
forwarded to a collection agency (bank charge for cheques with insufficient
funds is $20.00 per party). Failure to pay an outstanding account
will result
in all further treatments or procedures being cancelled.
DATE: ___________________________
PATIENT'S SIGNATURE* :________________________________
* OR SIGNATURE OF PARENT/GUARDIAN IF PATIENT IS UNDER THE
AGE OF 18 yrs.
Copyright ©2001 Freitag Homeopathics Inc.