Consent Form For Homeopathic Assessment

CONSENT FORM FOR HOMEOPATHIC ASSESSMENT & TREATMENT

Patient Name

File No

Registrant Name

Registration Number

I acknowledge that I have been informed of and understand the assessment and recommended treatment above. I have discussed this and any related questions with the Homeopath and received satisfactory answers. I understand the nature, benefits, risks, side effects, financial cost, and alternatives to the treatment, as well as the consequences of not proceeding. I understand I may withdraw my consent at any time. I hereby voluntarily give my informed consent for the recommended treatment.

Patient or Lawful Representative Signature

Date Signed

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 Date Signed

Relation to Patient

Address

Phone

*witness signature is advised but not required