Acknowledgement of Information and Understanding
I, the undersigned, acknowledge that I have been informed of and understand the assessment and recommended treatment described above. I have discussed this information to my satisfaction with Anica Elizabeth and have had the opportunity to ask questions.
Explanation of Treatment and Alternatives
I confirm that I have been briefed on the nature of the treatment (approach, methods, and purpose), its anticipated benefits, potential return of old symptoms, financial obligations, and the implications of declining treatment (condition remaining unresolved or worsening). I am aware of alternative courses of action available to me.
Possible Symptoms During Treatment
Homeopathic remedies may occasionally lead to a temporary worsening of pre-existing symptoms or the reappearance of old symptoms as part of the healing process.
Communication in Case of Issues or Acute, Urgent, and Semi-Urgent Issues
If I experience any issues that I believe are related to the remedies, I will immediately stop using them and contact Anica for guidance via email at newmoohomeopathy@hotmail.com.
For acute issues, I will schedule a 15–30 minute video consultation to review the symptoms. During this consultation, Anica will provide recommendations. Text updates will be required twice daily (morning and evening) for up to 5 days to monitor progress. Additional phone support may be offered during this time to assess if a remedy change, new acute remedy, potency adjustment, or redosing is needed.
I understand that the extended acute care comes with a $130 flat fee. However, if I have already paid the $90 acute care fee, the cost for the extended service will be an additional $40.
Responsibility for Primary Care and Emergency Access
It is my responsibility to maintain a relationship with a licensed physician for appropriate evaluations and emergency care. I understand that homeopathic advice is not a medical diagnosis or a replacement for a licensed medical or mental health care professional’s recommendations. If there is a medical emergancy I undestand that it is my responsiblity to seek immediate attention from medical professionals.
Recommendations and Supplementation
As part of my treatment, I may receive recommendations that include natural supplements or lifestyle and diet adjustments. I understand the importance of following suggested dosages and guidelines.
I acknowledge that New Moon Homeopathic Clinic does not supply supplements, and it is my responsibility to obtain them individually.
Withdrawal of Consent
I understand that I can withdraw my consent at any time and that the decision to seek homeopathic treatment is solely mine.
Role of the Homeopath
I understand that my Homeopathic practioner evaluates my entire condition based on a holistic, homeopathic approach which will be met with homepopathic remedies. I acknowledge that the homeopath has informed me that any treatment provided is as indicated. Homeopathy is not intended to replace or act as an alternative to medical care recommended by a physician. I am aware that the outcome and duration of homeopathic treatment can vary by individual and cannot be guaranteed.
I understand that it may take up to 4 days to a week to receive my personalized treatment plan after the initial consultation.
Appointment Recordings
Appointments may be recorded to ensure accurate documentation of the consultation and to aid in preparing an effective treatment plan tailored to your needs. These recordings are kept confidential and are only accessible by the homeopath, Anica Elizabeth, for the purpose of optimizing your care and will be only used to 2-4 days after then destroyed entirley when electronic medical record notes are filed and signed in the secure system.
I acknowledge that any video recording (audio or video) of any paid appointments will need consent of the practitioner and any reproduction, posting or sharing is prohibited.
Collaboration with Homeopaths
I understand that Anica Elizabeth may consult with fellow homeopathic colleagues about my case to ensure optimal care. Any information shared will be strictly limited to what is necessary and will remain confidential at all times.
Insurance Coverage
I understand that homeopathy is not covered by OHIP (Ontario Health Insurance Plan). While some private insurance plans may include homeopathy under their Extended Health Care coverage, it is my responsibility to confirm coverage with my provider.
I understand that New Moon Homeopathic Clinic does not file forms for insurance reimbursement. I also understand that the clinic encourages their patients to investigate all options for insrance reimbursement.