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Patient Forms

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If you are Physician and would like to refer patient, please visit Patient Referral Form

Patient Statement of Consent

I am willing to provide the Natural Health Clinic of Halton all information relevant to my health. I understand that this information will be used only for the purposes of my treatment, in order to fully understand my symptoms, my health history, and my health goals. I will provide this information voluntarily with the purpose of obtaining optimal healthcare. I also understand that this information will remain completely confidential, unless I have given my explicit written consent for disclosure. I acknowledge that my name, address and phone number will also be used for billing purposes and to book and confirm appointments.

I do hereby acknowledge that I have been informed of and understand the recommended treatment procedures, and I am aware that I have the choice to accept or reject this care at my own free wi ll, at any time during treatment. I further acknowledge and confirm that I have been informed of and understand the procedures with respect to the financial costs, expected benefits, potential risks and side effects. I have also been informed of the likely consequences of not following the recommended treatments, as well as what alternative course(s) of action are available to me. I understand that just like other forms of medicine, treatment modalities offered at NHC does have its limits as a healing agent. I further understand that advice and/or treatments offered to me by my practitioners at NHC are not intended to substitute for or replace advice and/or treatment provided by my other healthcare practitioners.

This consent form is intended to apply to the entire course of my care at NHC. I understand that at any time I may (in writing) withdraw consent for any further treatment and discontinue treatment at any time.

Cancellation Policy

Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the therapists’ day that could have been filled by another patient. As such, we require 24 hours notice for any cancellations or changes to your appointment. Patients who provide less than 24 hours notice, or miss their appointment, will be charged a cancellation fee.

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