Amber MacPhail

DECLARATION AND CONSENT TO TREATMENT

Please note, Amber MacPhail is in the process of becoming, but is not yet a registered Naturopath. By signing this document, you are consenting to treatment in full knowledge of this.

Naturopaths minimize the risk of harmful side effects by supporting the body’s own ability to heal and by using the least invasive procedures for diagnosis and treatment whenever possible. However, even the gentlest therapies have potential for complications.

Some therapies must be used with caution in certain diseases such as diabetes, heart, liver or kidney diseases, or in specific patient populations such as pregnant or lactating women, very young children or patients taking multiple medications. It is very important that you inform your Naturopath immediately of:

• aggravation of pre-existing symptoms
• allergic reaction to supplements or herbs
• pain, bruising or injury from treatment
• fainting from treatment

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 unless so directed by myself or when law requires it. I understand that I may look at my medical record at anytime and can request a copy of it. I understand that information from my medical record may be analyzed for research purposes and that my identity will be protected and kept confidential.

I understand that my Naturopath will answer any questions that I have to the best of his/her ability. I understand that the results are not guaranteed. I do not expect the Naturopath to be able to anticipate and explain all risks and complications. I will rely on the Naturopath to exercise judgement during the course of the procedure which they feel at that time is in my best interests, based on the facts then known.

I intend this consent form to cover the entire course of treatment for my present condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time.

If I am unable to make my appointment, I must provide advance notification within 24 hours, in which no charge will be applied.

THIS IS TO ACKNOWLEDGE that I have been informed and I understand that:
I. Any treatment or advice provided to me as a patient is not mutually exclusive from any treatment or advice that I may now be receiving from another licensed health care provider, or may receive in the future;

II. I am at liberty to seek or continue medical care from a physician or surgeon or other health care provider;

III. No employee, student or anyone else under the Clinic’s direction or control is suggesting or advising me to refrain from seeking or following the directions of another licensed health care provider;

IV. The treatment and therapies rendered or recommended by this Clinic may be different than those usually offered by a medical doctor or other licensed health care provider.

I DECLARE that I have received a full and complete explanation of the treatment of services that I may receive and hereby authorize and consent to treatment.

I AGREE to pay my full account at the time of each visit or treatment, including fees for services, cost of supplements and remedies, as well as other applicable fees. Notice of 24 hours is required for appointment cancellation, otherwise a $35 administrative fee will be charged.

Please note that the clinic is located on a working farm with a strong flowing river located nearby. All visitors should take care of:

• Interfering with plant or equipment, including electrical installations or fences;
• Entering unauthorized areas or farm buildings;
• Disturbing or unnecessarily approaching farm animals or work activities;
• Letting children wander unsupervised;
• Ignoring instructions or warnings; and
• Leaving gates open or damaging fences.