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.
Disclosure, Terms & Conditions:
1. Dr. Taufiq Binjemain's Qualifications:
Dr. Taufiq Binjemain graduated from the University of Leeds, UK in 2000 and has obtained various certifications and memberships, including Membership from the Royal College of Surgeons, Edinburgh (MRCS), Membership from the Royal College of General Practitioners (MRCGP), Canadian Family Physician Board Certification (CCFP), and a Fellowship from the Royal Australian College of General Practitioners (FRACGP). He has extensive training and experience in multiple medical specialties.
2. Approach to Personalized Medicine:
Dr. Binjemain believes 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. Dr. Binjemain integrates conventional medicine with complementary modalities to provide comprehensive care.
3. Collaboration with Medical Specialists:
Dr. Binjemain works alongside oncologists, psychologists, and other medical specialists to ensure the best possible outcomes for patients. For patients with a cancer diagnosis, he acknowledges the importance of standard-of-care cancer management and will refer patients to medical oncologists, surgeons, or radiation oncologists as necessary, with the patient's consent.
4. Consultation Triage and Billing:
Due to the high volume of consultation requests and the nature of certain diseases, patient appointments will be prioritized based on urgency, particularly for Stage 4 cancer or pancreatic cancer cases over other patients with a chronic non-cancer diagnosis. 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 and $220 for Heidi. There is a 1.1% surcharge on all electronic payment methods.
5. Off-Label Prescription of Drugs:
In some situations, Dr. Binjemain may prescribe off-label use of certain medications as an adjunct to standard-of-care treatments. For eg. medications, such as Metformin and Atorvastatin, etc., which are typically used by GPs for managing diabetes or high cholesterol, have shown effects on inhibiting the metabolism of cancer cells in lab studies. Although randomized controlled clinical trial data may still be lacking, these medications have been used in general practice for decades and have well-known safety profiles and potential side effects, which will be discussed with the patient during the consult. 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:
Dr. Binjemain fully supports patients who have been diagnosed with cancer to pursue standard-of-care medical treatments for their cancer diagnosis, including surgery, chemotherapy, immunotherapy, targeted therapy, hormone therapy, or radiation. We believe that standard-of-care treatments are vital for a positive outcome. We encourage patients to work in conjunction with their oncologists. Dr. Binjemain does not promise or guarantee a cure or specific outcomes for any condition, especially cancer.
7. General Consent:
WillowVale Clinic offers certain accessory functional pathology tests, treatments, and products that may not be covered by Medicare or PBS (Government Funding) or Private Medical Insurance. These tests and treatments are supported by empirical knowledge and are used with utmost care by Integrative Medical Practitioners.
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.
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 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 am aware that private fees will be applicable for my consultation, supplements, or treatments at WillowVale Clinic, and these fees are not eligible for reimbursement by Medicare or insurance. The specific consultation fees will be clearly communicated to me by my doctor prior to treatment.
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 or Zoom 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 too. 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 psychologist 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.
11. 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.