Consent Form For Homeopathic Assessment

CONSENT FORM FOR HOMEOPATHIC ASSESSMENT & TREATMENT

Patient Name

File No

Registrant Name

Registration Number

I, the undersigned, acknowledge that I have been informed of and understand the assessment and recommended treatment, including referrals. I have discussed this with the Homeopath, had the opportunity to ask questions, and received satisfactory answers. I understand the nature, benefits, risks, side effects, and costs, as well as alternatives and the consequences of not proceeding. I understand I may withdraw consent at any time and voluntarily consent to the treatment.

Patient or Lawful Representative Signature (IN CAPITAL LETTER'S)

Witness Signature

Relation to Patient

Address

Phone Number

*witness signature is advised but not required

Refusal of Consent

I understand that I can withdraw my refusal of consent.

I also understand that my refusal of above consent is contrary to the recommendation of my Homeopath. As a result I do hereby voluntarily and on an informed basis refuse consent for the recommended procedure(s) specified above.

Patient or Lawful Representative Signature

Date Signed

Witness Signature

Relation to Patient

Address

Phone Number

*witness signature is advised but not required