I, FULL NAME* understand and voluntarily agree that I am choosing to
participate in a medical retreat stay at The Health Lodge to improve my health. I freely and
voluntarily agree to receive the treatment provided and accept the agreement as follows and
understand should I fail to meet any of the agreements, The Health Lodge has the right to end my treatment and stay. 

I understand and acknowledge that receiving support at The Health Lodge is not a substitute for hospital.  INITIALS*

I declare that I am medically stable and have shared all aspects pertaining to my health with The Health Lodge. INITIALS*

I will keep (and be on time for) all my scheduled appointments with all members of my treatment team INITIALS*

I will inform my practitioner(s) of any changes in my condition or circumstance as they present.  INITIALS*

I will always follow the guidance and direction of my practitioners and clearly communicate with themINITIALS*

I understand that medication alone is not sufficient treatment for my disease, and I agree to participate in the patient education and relapse prevention programs, as provided, to assist me in my treatment. INITIAL*

I will freely attend hospital, if advised by The Health Lodge treatment team. INITIAL*

Whilst attending my Medical Retreat, I will not seek or participate in any other courses or care, without approval from The Health Lodge treatment team. INITIALS*

I will take my supplements as directed by my practitioner team. INITIAL*

I will take my medication as instructed and not change the way I take it without first talking to the doctor or other member of my treatment team.  INITIAL*

I agree that the medication and supplements I receive is my responsibility and that I will keep it in a safe, secure place. I agree that lost medication will not be replaced regardless of the reasons for such loss INITIAL*

I will follow the dietary guidelines and eat the food supplied, as set out by my practitioner(s). INITIAL*

I understand that the diet I will be given is to support my health and wellness and I will not solicit food outside of this diet without approval. INITIAL*

I understand that I can make use of the kitchen at The Health Lodge. I understand that the kitchen will open from 9am Mon-Saturday and close at 6pm on weeknights, 2pm on Saturdays and will be closed on Sundays. I will have to take the food I would like to consume outside kitchen hours to my room. INITIAL*

I will treat the property, treatment and accommodation rooms with respect. I understand if I cause any damage to the premises, I will be responsible for the cost of the repair. INITIAL*

I understand that there is no night care at The Health Lodge during my stay. If night care is required, I understand there will be additional costs incurred by me. INITIAL*

I understand that there is no designated nursing staff on site during my stay. If specific nursing care is required, I understand there will be additional costs incurred by me.  INITIAL*

I understand that THL does not have staff on site on weekends and there is no access to the kitchen. INITIAL*

I understand that I will contact Simon Dubois on 0401 440 329 or Oliver McElligot on 0478 701 817 in the event of the fire alarm going off during the night. INITIAL*

I will maintain a strict non-smoking policy on the premises of The Health Lodge during the program. INITIAL*

I will maintain a non-alcohol policy on the premises of The Health Lodge during the course of the program. I will make every effort not to consume alcohol during the course of the program. INITIAL*

I will not consume illicit drugs during the course of the program. INITIAL*

I agree not to source drugs or alcohol during my stay. I understand that mixing my medications with alcohol can be dangerous. INITIAL*

I will treat the staff and office respectfully at all times. I understand that if I am disrespectful to staff or disrupt the care of other patients my treatment will be stopped. INITIAL*

If I am feeling agitated and/or frustrated, I will respectfully let staff and/or my practitioner(s) know how I am feeling, as to ensure ongoing respect in communication and my actions towards others.   INITIAL*

I will listen to and treat my practitioners and their advice with respect and follow their guidance to ensure effective care and treatment. INITIAL*

I understand that I can contact the Mental Health Access Line on 1800 011 511 or Lifeline on 13 11 14 if my mental health deteriorates. INITIAL*

I agree that if I am concerned about my health situation, physical or mental, that I will go straight to Byron Bay Hospital, 54 Ewingsdale Rd, Ewingsdale NSW 2481, Phone: (02) 6639 9400. In the situation where there has been a night nurse arranged for me, I will contact the nurse (number will be provided on day of arrival). INITIAL*

I understand that the cost of supplements, Intravenous Vitamins and other external services that are not included in my package are to be paid at the end of each day. INITIAL*

I understand that extra sessions requested or suggested outside of my program (10 day program $14,200 plus GST is 24 sessions) will be billed to my credit card on file at the end of each day. INITIAL*

I understand that there is no night care at The Health Lodge during my stay. However, I understand that if overnight nursing is deemed necessary by my THL team, the cost will be $1000 per night billed to my credit card on file unless otherwise specifiedINITIAL*