I, the undersigned patient or legal guardian, hereby acknowledge that I have read and understood the disclosure, terms, and conditions provided below, and I consent to the medical care and procedures outlined by Dr. Taufiq Binjemain and other health practitioners at WillowVale Clinic.
Disclosure, Terms & Conditions:
1. Dr. Taufiq Binjemain's Qualifications:
Dr. Taufiq Binjemain graduated from the University of Leeds School of Medicine, UK in 2000 and has obtained various certifications and memberships, including Membership from the Royal College of Surgeons, Edinburgh, Membership from the Royal College of General Practitioners, Canadian Family Physician Board Certification (CCFP), and a Fellowship from the Royal Australian College of General Practitioners. He has extensive training and experience in multiple medical specialties.
2. Approach to Personalized Medicine:
Our doctors believe in personalized medicine, focusing on the uniqueness of each individual and addressing the underlying causes of chronic illnesses. This may involve comprehensive testing and analysis to determine factors such as genetics, psychology, past trauma, toxicities, lifestyle, nutrition, and metabolism. Our doctors integrate conventional medicine with complementary modalities to provide comprehensive care.
3. Collaboration with Medical Specialists:
Our doctors work alongside oncologists, psychologists, and other medical specialists to ensure the best possible outcomes for patients. He acknowledges the importance of standard-of-care cancer management and will refer patients to medical oncologists, surgeons, or radiation oncologists as necessary.
4. Consultation Triage and Billing:
Due to the high volume of consultation requests and the nature of the disease, patient consultations will be prioritized based on urgency, particularly for Stage 4 cancer or pancreatic cancer cases. Consultations are available by appointment only and will be billed based on a 15-minute block at the current hourly rate of $600 for Dr. Binjemain, $500 for Dr. Xavier, and $300 (or $350 for 90mins) for Laura. There is a 1.7% surcharge on all electronic payment methods.
5. Off-Label Prescription of Drugs:
Our doctors may prescribe off-label use of certain medications as an adjunct to standard-of-care oncological treatment. These medications, such as Metformin, Atorvastatin, Doxycycline, etc., have shown potential in the context of cancer treatment, although randomized clinical trial data may be lacking. These medications have known safety profiles and potential side effects, which will be discussed with the patient. Regular monitoring and follow-up appointments will be scheduled to assess the patient's response and adjust the treatment plan if necessary.
6. Consent to Standard Medical Intervention:
Our doctors fully support patients pursuing standard-of-care medical treatments for their cancer diagnosis, including surgery, chemotherapy, immunotherapy, targeted therapy, hormone therapy, or radiation. They encourage patients to work in conjunction with their oncologists and do not promise or guarantee a cure or specific outcomes.
7. General Consent:
WillowVale Clinic offers certain accessory functional pathology tests, treatments, and products that may fall outside the parameters of conventional medicine in Australia. These tests and treatments are supported by empirical knowledge and are used with utmost care by Integrative Medical Practitioners. Some tests and treatments may not be covered by Medicare or private health insurance funds.
8. Communication via Email/Text:
By signing this form, you consent to communicate with WillowVale Clinic via email, online forms, and/or text message. You acknowledge that email, online forms, and text communication may not be completely secure and that any decision to use such communication will be documented in your clinical records. You understand that confidentiality will be respected, and emails or texts will not be forwarded without the consent of all parties involved. I am signing to confirm that I have understood the conditions as set out above and have been made aware of the associated risks with regard to data protection.
The health practitioners at WillowVale Clinic will not be able to call or email a patient outside of a consult and they spend almost all their time at the clinic in consultation with clients face-to-face or via telehealth or telephone.
Any medical questions are best handled in the context of a consultation. We recommend first checking your consultation summaries or information sheets provided by the WillowVale Clinic practitioners, then making a face-to-face, phone, or telehealth consultation if the answer cannot be found.
Your emails are received and actioned by our wonderful Reception team; who are not clinical staff and cannot provide medical recommendations.
9. Fees and Supplements:
You acknowledge that there will be private fees applicable for consultations, supplements, or treatments at WillowVale Clinic, which may not be rebatable by Medicare or insurance. Consultation fees will be clearly specified to you by the admin team or your doctor prior to treatment. You understand the importance of following the prescribed supplement regimen as directed by your doctor and agree to attend scheduled reviews.
I understand and acknowledge that practitioners at WillowVale Clinic may benefit, either directly or indirectly, from tests or supplements recommended at the practice.
I am attending WillowVale Clinic voluntarily and consent to receive treatment(s) based on my own judgment and the information provided to me. I understand that any information obtained during my time at the clinic may be used for research and publication purposes in a de-identified manner.
I also understand the results are variable between different individuals.
It is important that I take these prescribed supplements as directed by my doctor.
I will return for a review of my health on the date which is specified by my doctor.
If I fail to attend these reviews then I will no longer take any of the supplements prescribed to me by the doctor after the specified review date.
I understand that these supplements are only prescribed for me and are not to be used for anyone else.
I understand that prolonged taking of certain supplements at high dosages without medical supervision could lead to adverse health outcomes such as nerve and thyroid disorders. I will direct any questions or concerns to my Doctor during my consultations. Some of the products are not TGA listed and may need a SASB form filled in on my behalf.
10. Confidentiality
All information gathered in the provision of medical services will remain confidential and secure except where:
1) There is a serious and imminent risk to yourself or someone else
2) There is reasonable suspicion a child is at risk or is being mistreated
3) Your records are subpoenaed by a court
4) Your prior approval has been obtained to provide a written report to a requested professional agency (e.g.specialist, university, lawyer, etc) or to discuss information with another person (e.g., family member, employer)
11. Telehealth Consent & Information
In 2020, in response to the COVID-19 Pandemic, telehealth services were introduced and have been extended until December 2026.
Our practice predominantly utilises Halaxy Telehealth, Zoom, Skype, or other video apps to deliver our telehealth services. Privacy remains as per our usual process, refer to the Confidentiality section in this document, and we will treat your information with respect and in confidence. We will not record telehealth sessions nor share material from telehealth sessions without your consent. Telehealth services utilise interactive cloud-based systems that involve sharing of audio, video, or other data communication online (outside of our practice). Our practitioners make a commitment that we will undertake these calls in a private setting where others cannot hear your information. We recommend that you also find a private setting where you feel comfortable. It is important that steps are made by you to protect your information. If you are not able to find a private location where you feel comfortable let your health practitioner know when they call and they will respect your request. Your privacy is important, and we will respect your decision.
12. Safety & Confidentiality
If your medical team is concerned about your safety or the safety of others, the usual limitations (as outlined in the Consent section in this document) apply. If your practitioner fears for your safety during or upon the termination of a session, they may contact the emergency contact person (nominated by you) to ask them to check on you. Your practitioner will make every effort to ensure you are feeling safe and supported, however, due to the nature of online telehealth services there will be a greater need for you to utilise your self-regulation strategies. If you are concerned about your level of ability to self-regulate, please discuss with your practitioner and they can work with you to develop these skills to ensure you feel safe and grounded in between sessions.
13. Consent for Telehealth Services
I accept the method of Telehealth services, and I have read, understand, and agree to the above information. I agree to pay the negotiated fee as per one of the options provided. I also agree to my doctor or psychologist lodging the rebate with Medicare on my behalf, should my bank details be registered.
I have read and understood this Consent Form. I agree to the conditions outlined above for the provision of medical services at WillowVale Clinic. I consent for WillowVale to take notes during the consultation and keep them in a confidential file. I have read and understood the Consent for Telehealth Information. I agree to the conditions outlined above and consent to Telehealth Services from WillowVale Clinic should I require Telehealth Services. I have read, understood, and agree to the information and conditions outlined above by WillowVale Clinic.
14. Cancellations & Appointment Policy
The clinic has implemented the following policies due to a high demand for services and the long waiting list for patients. Late cancellations and no shows for appointments mean that the clinic is unable to offer these appointments to other patients who require urgent access to these treatments.
Patients are required to arrive at the clinic 10 minutes prior to their scheduled appointment time.
If a patient arrives late, the treatment will still end at the originally scheduled time. The full duration cannot be extended, and only the remaining time will be used.
Cancellations must be made at least 2 whole business days prior to the scheduled appointment.
Late cancellations (less than 2 whole business days' notice) will incur a cancellation fee of 100% of the consultation or treatment fee.
Cancellation messages left on weekends or after-hours will be treated as made on the next day the practice is open.
No-shows may be charged the full appointment fee.
Rescheduling/ Rebooking appointments must be done 48hours prior to the appointment
15. Refund Policy
Bookings
Due to high demand and to ensure the ongoing effective and efficient provision of services, WillowVale Clinic requires patients to pay a deposit amount to secure their appointment. The deposit amount will be credited towards your appointment. We require a credit card to be added to your file to secure your appointment.
Below is our policy for the refund of these amounts.
Deposits for Appointments:
Cancellations made more than 14 days before the appointment will receive a 100% refund.
Cancellations made between 7 and 14 days before the appointment will receive a 50% refund.
Cancellations made less than 7 days before the appointment are non-refundable.
Treatment Packages:
Refunds for prepaid treatment packages are as follows:
Hyperbaric Therapy – Non-refundable*
Remission Packages – 50% refundable on the unused portion, subject to a minimum portion of 6 hours being used*. The used portions will then be deducted or charged at the non-packaged (undiscounted) price.
Red Light Bed – Non-refundable*
Infrared Sauna – Non-refundable*
The non-refundable treatments can be gifted to another person and will need to be used within 3 months of purchase, at which point they are deemed void.
Single Sessions booked must be prepaid and if cancelled within 24- 48hours 50% refund within 72 hours prior to the appointment full refund
If you do not believe you can commit to the number of sessions contained in the treatment packages, we encourage you to book single sessions instead.
*Please note that refunds are not provided for a change of mind. Refunds will be provided where required in accordance with the Australian Consumer Law.
WillowVale Clinic may, in some circumstances, exercise its discretion to refund treatment packages, as we understand that there can be extenuating circumstances. This is assessed on an individual, case-by-case basis.
16. Terms & Conditions
By booking and paying for treatments or packages, patients agree to abide by all clinic policies, including cancellation and refund terms. These policies are in place to ensure fairness, effective scheduling, and the highest standard of care for all clients.
17. Acknowledgment:
By signing below, you acknowledge that you have read and understood the disclosure, terms, and conditions outlined above. You understand the nature of our health practitioners' practice and have consented to the terms and conditions.