INFORMED CONSENT AND RELEASE

By signing this form, you acknowledge that you have received our “Notice of Privacy Practices” (the “Notice”). This Notice describes in detail how we might use or disclose your protected health information. The Notice also discusses your rights and our duties with respect to your protected health information. You have the right to review the Notice before signing this acknowledgment.

I authorize and request the clinic to charge my credit card for balances due for services rendered that my insurer identify as my financial responsibility or non-covered services. This authorization will remain in effect until I cancel this authorization. To cancel, I must give a 60-day notification to the clinic in writing and the account MUST be in good standing. Without this authorization, our financial policies will apply and you may risk being sent to collections after ninety (90) days for nonpayment. If you have an unpaid balance and have neither a credit card on file nor a payment plan established, you will be required to pay your balance prior to your next visit.

I understand that by signing this agreement, I consent to all general Naturopathic care and/or routine services, including evaluation, therapies, and diagnostic testing provided under the general or specific instruction of my physician(s) and other health care providers, in-person or via telemedicine. I understand that my physician(s) or other health care providers may be accompanied and/or assisted by students, interns, and residents during my care.  I consent to the presence and/or participation in my treatment by these persons while under the direction or supervision of my physician(s) or other authorized health care providers.