Vaid Rubal's Online Consent Form & Consent to the Collection, Use and Disclosure of Personal Health Information- Vaid Rubal's Clinic Ltd

Consent Form:

Herbal  Medicine  is  the  treatment  and  prevention  of  diseases  by  natural  means.  As  a  Registered  Natural  Consulting  Practitioner  (R.N.C.P.) & Ayurvedic Practitioner  I  asses  the whole  person,  taking  into  consideration physical, mental, emotional and spiritual aspects of the individual. Individual  diets  and  nutritional  supplements  are  recommended  to  address  deficiencies,  and  promote  health.  The benefits include energy, increased gastrointestinal function, improved immunity and general well being.

Botanical  Medicine  is a  plant  based  medicine  using  herbal teas, tinctures, capsules and  other  forms  of  herbal preparations  to  assist  in  the  recovery  from  injury  and  disease.  These compounds are also used to boost the body’s immune system as well.  Herbal Medicine is a holistic approach to health, lifestyle is considered relevant to most health problems.  I will try to help you to identify risk factors and make recommendations to help you optimize your physical, mental and emotional environment. Even  the  gentlest  herb  has  its  complications  in  certain  physiological  conditions  such  as  pregnancy  and  lactation,  in  very  young  children  or  those  with  multiple  medications.  Some herbs must be used with caution in certain diseases such as diabetes, heart, liver or kidney disease.  It  is  very  important  that  you  inform  me  immediately  of  any  disease  process  that  you  are  suffering  from  or  if  you  are  taking  any  medications.  If you are pregnant, suspect you are pregnant or you are breast-feeding please inform me as well.  There  are  some  slight  health  risks  to  treatment  by  Herbal  medicine.  These include but are not limited to: Temporary aggravation of pre-existing symptoms such as temporary swelling on hands, feet, face, legs or arms, weight gain or weight loss, Allergic reactions to herbs or supplements , such as skin rash, abdominal cramping, diarrhea, constipation, heartburn, dry mouth or loss of tastiness. Therapies can be suggested to you such as, Cupping, Ultrasound, Tense, Inversion Table, Massage, Nasya, Natrevasti, Shirodhara, Panchkarma,  ect. There may be minor side effects such as Temporary aggravation of pre-existing symptoms, skin bruising, headaches, skin rash, although highly unlikely to happen - blindness,  sneezing , coughing, over sensitivity to light as examples. It is important that you follow the after-care instructions on any given therapies.

A record will be kept of the services provided to you.  A copy of your transcript can be made available to you at the cost of $100 per page for legal purposes. This record will be kept confidential  and  will  not  be  released  to  others  unless  you  give  your  consent  or  the  law  requires  it.

I ,understand   that  my  Registered  Natural  Consulting  Practitioner  will  answer  any  questions  to  the  best  of  his  ability.  I understand that results are not guaranteed.  I  do  not  expect  him  to  be  able  to  anticipate and explain all  risks and complications.  I will  rely on  his judgment  during the  course  of  the  participation  which  he  feels  at  that  time  is  in  my  best  interests  based  on  the facts then known. I will consult with my family physician prior to taking any herbal remedy/therapy. I also agree that I have read and understand the information stated above and will not hold the practitioner responsible.

Consent to the Collection, Use and Disclosure of Personal Health Information:

Note to client: We want your informed consent. We want you to understand what we do with the personal health information we collect about you. Please ensure that you have read and understood our written statement, “Privacy Policy” located inside the clinic on the Bulletin board. If you have any questions, please ask.I, understand that to provide me with [type of health care goods or services], [Vaid Rubal's Clinic ltd] will collect personal information about me (e.g., birth date, home contact information, health history, etc.). I have reviewed the [Vaid Rubal's Clinic ltd.] written statement on the collection, use and disclosure of personal health  information. I understand how the written statement applies to me. I have been given a chance to ask questions about the privacy policies and they have been answered to my satisfaction.

I understand that Vaid Rubal's Clinic ltd. will only collect, use or disclose my personal health information with my express or implied consent, unless a collection, use or disclosure without consent is permitted or required by law.

I further authorize Vaid Rubal's Clinic ltd. to collect, use and disclose my personal health information for the following purposes;

a) to use or disclose your personal health number to verify your identity or to access other personal health records about you in order to provide health care services to you.

b) to notify me of new services or goods available at Vaid Rubal's Clinic ltd. via provided email address 

c) to notify me of special events and opportunities at Vaid Rubal' Clinic ltd (e.g. a seminar or conference)