133 Sunnyside Road
RR#2, Westport, ON,
K0G 1X0


 

                                                                      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)  $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 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.
 

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                                                                                Copyright ©2001 Freitag Homeopathics Inc.