Patient intake form

Please take the time to complete the following information for our records. The information shared will be kept confidential and never shared with outside parties. If anything is unclear, please do not hesitate to contact us.
Patient intake form

Do you consume any of the following? How much?

1. I acknowledge that I am responsible for my account and those of my dependents.

2. I acknowledge that I will settle the account at the time of the consultation and it is my responsibility to submit all claims to my Medical aid for reimbursement.

3. I agree to be punctual for scheduled appointments.

4. The consultation fee includes time in consultation, dispensing time and administrative time spent.

5. Appointments cancelled less than 24 hours in advance will be charged for in full and future appointments will need to be settled in advance.

6. I hereby grant permission for the practitioner to use any modality, within their scope of practice, which may be deemed beneficial in the treatment of my health concerns.

7. While fully understanding that the Practitioner will engage to the best of their ability to assist with or resolve my health concerns, I accept that there is no guarantee that the treatment or interventions will be successful.

8. Neither the practitioner, nor any of their employees will be responsible or liable for any loss, theft or damage, however caused,  to my property or vehicle while on the premises.


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