*EH CLIENT POLICIES & WAIVER

Your Full Name*

First NameLast Name

Psy Integrated Health is a management services organisation that provides space and administrative services to independent healthcare and wellness practitioners (“Practitioners”), who provide multidisciplinary, integrative health and wellness services to you, your family and our community, through our Empower Health Wellness Centre ("Empower Health"), located at #305-2730 Commercial Drive, Vancouver, BC. These Practitioners, in turn, collaborate as a team to deliver programs, processes and tools to help you meet your health and wellness goals.

To provide you with the best possible care, Practitioners practicing out of Empower Health share an Electronic Medical Record (EMR) system. All Practitioners and staff are bound by Privacy & Confidentiality Agreements to protect your privacy. Practitioners must also fully comply with the privacy regulations of their professional colleges and regulatory bodies and the privacy laws of British Columbia and Canada.

Please CHECK the following to indicate your understanding and consent:*

I understand that my health file is accessible to the Practitioners and staff of Empower Health and, with my consent, my health history and treatment plan may be discussed amongst the Practitioners and staff who work at Empower Health for the purpose of providing me with integrative health and wellness services.My personal and medical information is confidential. My personally identifying information will only be disclosed to third parties with my written permission or as permitted by law. However, de-identified versions of my medical records may be shared with third party researchers who may request access to the data for retrospective analysis. Averaged group data may be published or publicly presented, but it will not be possible to identify me from this data

You are always in control! And we are here to help, meaning that you have the right to give, refuse or withdraw consent to any treatment at any time, and this will not affect your ability to receive care in the future (CHECK):*

I have the right to give, refuse or withdraw consent to any treatment or treatment plan at any time, and this will not affect my ability to receive care in the future.I understand that I am free to pursue other medical opinions and treatments including conventional medical care at any time. I understand that no warranty or guarantee regarding a promise of cure as a result of care is provided for any condition by Empower Health.

Payment and Cancellation Policies:*

At the end of each visit with Empower Health, you are responsible for the full payment of any fees incurred during your visit. We require at least 24 business hours notice if you wish to cancel or reschedule your appointment; otherwise, you will be charged for the full appointment, and, in the case of a scheduled treatment, the cost of non-reusable products that have been prepared for you. Notice of cancellation or rescheduling must be given during regular centre hours or prior to regular centre hours covering this 24-hour period. (Note: Monday appointments must be canceled on Saturday). I understand that Empower Health may store my credit card information in a secure system, and that I will automatically be charged for late cancellations as per the policy provided herein.

Communication of Medical and Health Information: Email is not a preferred method of communicating health data due to risks of breach of confidentiality. If you choose to send health data over email, we are obligated to inform you that email is not a medically encrypted medium.

By checking here, you are confirming that you are aware of the risks involved in digital communication and give Empower Health written confirmation that you are willing to accept these risks by allowing the staff at Empower Health to send or receive your personal information and medical files via email.

Code of Conduct:

At Empower Health it is important to us that we provide our team, staff and clients with a safe environment. We do not condone any form of violence whether verbal or physical in nature. Possession of illicit drugs or alcohol on the premises is not allowed. Attending sessions/appointments “under the influence” may be grounds for restriction of privileges, rights, and services, or termination/discharge. Weapons (including but not limited to firearms) are not allowed on the premises. Client will be considered non-compliant for repeated and or/deliberate violation of Psy Integrated or Empower Healths’ rules or policies. By checking here you are indicating understanding and agreement to the above Code.

Extended Health Insurance and MSP:

Many extended healthcare insurance providers cover naturopathic, massage therapy, acupuncture, physiotherapy and osteopathic services. Some also cover counselling visits.

We bill directly to a number of extended health providers. However, we cannot guarantee your coverage for any of the services. You are solely responsible for full payment at the time of visit - therefore, we strongly recommend that you check your coverage terms with your plan administrator or via your company-provided Benefits Booklet in advance of your visit. We do not direct bill for MSP Premium Assistance coverage, however we can provide you with a receipt. Please ask our reception staff about your eligibility.

Disclaimer:

Psy Integrated Health Inc. (DBA Empower Health) does not provide health services to the public. All such services (the “Services”) are provided by the various independent health and wellness Practitioners who operate through Empower Health Wellness Centre. Any questions or concerns specific to programs, services or procedures must be directed to your Practitioner(s).

Psy Integrated Health Inc. expressly denies any liability associated with the provisioning of Services by any Practitioner. By signing this informed consent, you acknowledge and agree that Psy Integrated Health Inc. is not liable for any claim(s) arising from the relationship between you and any Practitioner, including any acts or omissions of any Practitioner related to the services or treatment provided by such Practitioner, and that you will indemnify and save and hold harmless Psy Integrated Health Inc. against any such claims that you or your personal representatives may have in such regard.

Signature of Client:

Signature of Guardian

Clear

Guardian Name

First NameLast Name

Today's Date

MonthDayYear

Email

example@example.com

Enter the message as it's shown*

New Client Policies & Waiver