PLEASE READ THE FOLLOWING CAREFULLY.
*If under 18 years old, a parent or guardian must sign.
I, the undersigned, understand that Erin Richer is a Homeopath and not a medical doctor. As such, I acknowledge that it is my right and responsibility, at any time throughout my treatment with Erin Richer, to seek medical counsel and diagnosis, if so desired, from a medical doctor, for any present and/or future condition(s). I also reserve the right to terminate homeopathic treatment at any time if so inclined. I acknowledge that the state of my health is my responsibilty and that I am exercising my right to choose an alternative method of treatment, in Homeopathy, through which to address my total health.
As Homeopathy is not covered by existing government insurance plans, I understand the cost of treatment and agree to pay according to the guidelines set by Inner Balance Homeopathy. Some extended health care plans do cover Homeopathy, I suggest you inquire with your provider.
Exclusive Jurisdiction
I further acknowledge that the healthcare and treatment recieved from Inner Balance Homeopathy will be provided in the province of Alberta, and that the Courts of Alberta shall have exclusive jurisdiction to hear any complaint, demand, proceeding or cause of action, whatsoever arising from or in connection with the healthcare and treatment, or from any other aspect of the relationship between myself and Inner Balance Homeopathy.
As a result, I do hereby voluntarily provide my informed consent for treatment from Inner Balance Homeopathy.