request and consent to receive care and treatment by Hayley Barnes (Practitioner) who is a qualified Naturopath, Nutritionist and Herbal Medicine Practitioner under Australian law.
I am aware that Naturopathic Medicine takes a holistic approach to wellness and health challenges and that the Practitioner assesses each individual as a whole and seeks to activate and support the self-healing mechanisms of the body. Treating the root cause of the health complaint. I understand that the Practitioner is not a medical doctor and that Naturopathic consultation and treatment is not intended to replace orthodox medical care or medical prescriptions.
I understand that different approaches and natural medicine may be used during the course of my treatment depending on my individual circumstances. These include, but are not limited to: Nutritional supplements, Practitioner only Products/Supplements, Herbal Medicine, Homeopathy, Flower essences, personalised nutrition, skincare and lifestyle prescriptions.
I understand, and am informed, that there are potential risks and benefits to these remedies or treatments including but not limited to those described below:
Possible risks: inconvenience of lifestyle changes, aggravation of pre-existing symptoms during the healing process; flare up of acne breakouts before treating and clearing acne, allergic reactions to prescribed remedies, side effects of natural medications such as gastrointestinal disturbance, rashes, headaches, and hypertension.
Potential Benefits: Clear, glowing, acne free skin, balanced hormones and nervous system, thriving gastrointestinal health, detoxified liver, healthy lymphatic system, increase in sleep quality, relief of pain and health challenge symptoms; weight loss, restoration of health and the body’s maximum functional capacity, correction of nutritional deficiencies, and prevention of disease and/or its progression.
I consent to my de-identified before and after photos to be used by the Skincare Academy Pty Ltd to inspire other women to finally treat the cause of their acne.
I understand the importance of taking my prescribed treatment and remedies according to the prescription and will contact the Practitioner if I have any questions or concerns. If I suffer any allergies, unpleasant symptoms or reactions from the remedies, I will cease taking them and will immediately contact the Practitioner for further instructions.
I do not expect the Practitioner to be able to anticipate and explain all possible risks and complications. I wish to rely on the Practitioner to exercise judgement during the course of treatment, which the Practitioner feels at the time, based upon the facts known, is in my best interests. I understand that results or specific outcomes are not guaranteed.
I agree to inform my Practitioner of:
- any medical conditions or diseases I may be suffering from (including any contagious diseases contractible by blood such as HIV, hepatitis);
all supplements and medications that I am taking (including any change in medications or dosages);
- any known allergies or sensitivities;
- if I am vegan or vegetarian (as some supplements contain animal products);
- if I participate in Halal or Kosher beliefs (as specific supplements will need to be tailored to you).
- if I am, or suspect I am, pregnant, open to being pregnant or breastfeeding, as certain treatments may be contraindicated.
I also agree it is my responsibility to inform my General Practitioner, Pharmacist or other health professional of the natural medications I am taking.
I understand and consent to the collection of my personal information (including my health information) by the Practitioner for the purpose of providing naturopathic treatment, and for other related purposes. I understand the collection, use, storage and disclosure of my personal information will be in accordance with Australian Privacy Laws and Skincare Academy Pty Ltd Privacy Policy at www.skincareacademy.com.au/privacy.
By providing my consent, I am also consenting to the Privacy Policy and collection of my personal information for such purposes.
By voluntarily signing the below, I acknowledge that I have read the above, and I have also had the opportunity to ask questions about its content. I intend this consent form to cover the entire course of treatment for my present condition, and for future condition(s) for which I seek treatment. I understand I can withdraw my consent and/or discontinue treatment at any time.