INFORMED CONSENT
Homeopathy is a form of medicine based on the Law of Similars – that is, the use of tiny doses of the very thing that causes symptoms in healthy people. These minute doses of plant, animal, or mineral origins are used to stimulate the body’s ability to heal itself. A homeopathy is a powerful tool that effects healing on a physical and emotional level.
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Lifestyle counseling involves identifying risk factors and making recommendations to help optimize
one’s physical, mental, and emotional environment. During your initial visits, your Homeopath will take a thorough case history, and any physical examination needed.
PLEASE INITIAL THE FOLLOWING:
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I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others without my consent unless required by law. I understand that I may look at my medical record at any time and can request a copy of it by paying the appropriate fee.
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I understand that the homeopath will answer any questions that I have to the best of their ability. I understand that the results are NOT guaranteed. I do not expect the homeopath to be able to anticipate and explain all risks and complications. With this knowledge, I voluntarily consent to the procedures mentioned above, except for (please list any exceptions):
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I understand that charges are to be paid at the time of the visit unless specific arrangements have been made. Payment for all dispensary items is due at the time they are received. As the patient, you are responsible for the total charges incurred for each visit. If you have coverage for Homeopathic Medicine through an insurance company, you are responsible for billing your own insurance company.
I have read and understood the above-stated information and policies. I intend this consent form to cover the entire course of treatment for my present condition. I understand that I am free to withdraw consent and to discontinue participation in these treatments at any time.
Revi Haviv
May 5, 2022 at 11:00:00 PM