FORM “B”
ACKNOWLEDGMENT
Our
program includes
a series of activities
and exercises,
diet and nutrition
and lifestyle
counseling, all
of which are designed
to help strengthen
the Nervous System
and improve overall
health. All of
our therapies
use non-invasive
methods for the
assessment of
bodily dysfunctions,
and natural therapeutics
for their correction.
In
order to avoid
any confusion
or misunderstanding,
we request that
all patients read
and acknowledge
the following:
•
That you understand
that the clinician
provides therapy
for the neurologically
disabled and is
not a Medical
Doctor. It is
best to see an
MD about your
condition, if
a straight medical
diagnosis and/or
medical treatment
is required.
• That you
understand that
the treatment
here and/or referral
to other health
professionals
is based upon
our evaluation
and the information
provided to us
during the interview.
• That
you understand
that our therapy
is not covered
under O.H.I.P
and, therefore,
you are responsible
for any fees incurred
while under treatment
by the clinician.
Furthermore, you
acknowledge that
you are fully
aware of the fee
schedule for services
at the clinic.
• You acknowledge
that the clinician
does not require,
advise or encourage
you to discontinue
any medication
or treatment prescribed
by your medical
doctor. If you
decide to do this
we encourage you
to consult with
your medical doctor
first.
• All patient
information is
strictly confidential
and all records
remain solely
the property of
AND at all times.
• That you
are here as a
patient and not
attending for
any other reason
without making
your intentions
known to the clinician
and/or to the
staff.
Please
be informed that
you are required
to give at least
48 hours of advanced
notice in case
you need to cancel
or reschedule
any appointment.
We regret that
otherwise a cancellation
fee of $50 will
be applied against
your credit card
for the missed
appointment. Under
certain circumstances
and at the sole
discretion of
AND, this fee
may be waived.
We greatly appreciate
your consideration
in this matter.
Patient's
signature: _________________________________
Date: ______________________
Click
Here to download
the document.
