CONSENT TO TREATMENT
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
acupuncture Testing, Application of Homeopathic Combinations, Acupuncture,
and Electrical Massaging (applicable to Patients treated at the Natural Medicine
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
(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
(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) $113 for the first test; and
(ii) $79.10 for each additional follow-up test.
(b) The cost per child is:
(i) $79.10 for the first test; and
(ii) $56.50 for each additional follow-up test.
The cost of the medication is an additional $25.99 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
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.
PATIENT'S SIGNATURE* :________________________________
* OR SIGNATURE OF PARENT/GUARDIAN IF PATIENT IS UNDER THE
AGE OF 18 yrs.
Copyright ©2001 Freitag Homeopathics Inc.