RECOMMENDED DIAGNOSTIC / THERAPEUTIC PROCEDURE(S)(including those by referral to another practitioner)
The therapies offered at this office are:Homeopathic and/or Herbal Medicines and/or Dietary Changes
I do hereby acknowledge that I have been informed of and understand the recommended diagnostic / therapeutic procedure(s) described above from reading Dr. Putnam’s website information and have discussed to my satisfaction this and any requests for related information with the Naturopathic Doctor named above and/or with his/her office or clinical assistant(s). I further acknowledge and confirm that, through other information provided on the website from which this form was downloaded I have been informed of, and understand the procedure(s) with respect to the nature of the procedure, expected benefits, potential risks, side effects and financial cost; the likely consequences of not having the procedure(s), and what alternative course(s) of action are available to me. I understand that I can withdraw my consent at any time.As a result, I do hereby voluntarily provide my informed consent for the recommended procedure(s) specified above.
In this Clinic, Dr. Richard Putnam, acts as the Privacy Information Officer.
All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are trained in the appropriate use and protection of your information.
- only necessary information is collected about you;- we only share your information with your consent;- storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols;- our privacy protocols comply with privacy legislation and standards of our regulatory body, the Board of Directors of Drugless Therapy – Naturopathy.
How Our Clinic Collects, Uses and Discloses Patients’ Personal Information
Our Clinic understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined here how our Clinic is using and disclosing your information.
This Clinic will collect, use and disclose information about you for the following purposes:- to assess your health concerns- to provide health care- to advise you of treatment options- to establish and maintain contact with you- to send you newsletters and other information mailings- to remind you of upcoming appointments- to communicate with other treating health-care professionals and billing- to communicate with insurance providers- to comply with legal and regulatory requirements of our regulatory body, - the Board of Directors of Drugless Therapy – Naturopathy acting under the authority of the Drugless Practitioners Act- to invoice for goods and services- to process credit card/debit payments- to collect unpaid accounts- to assist this Clinic to comply with all regulatory requirements- to comply generally with the law- to allow potential purchasers, practice brokers to conduct an audit in preparation for a practice sale
By completing the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information as outlined above.
The reality of this circumstance dictates that even the most brilliant doctors, despite years of education, find themselves humbled to a position where from they can but merely attempt to cure or alleviate their patients’ conditions. All that doctors are able to do is simply try to help their patients. Often they are successful, and often they are not. Evidence of this unspoken reality comes from the administrative offices for the various health professions which firmly instruct all their doctors to offer no absolute certainty of health results thereby potentially raising false hope.
Given these facts, this health practitioner endeavors to provide the best possible diagnosis and course of treatment understanding that many known and quite possibly unknown factors will be important in determining actual results. Therefore, no guarantee can be made with respect to any assessment methods, treatment or application of health care advice, financial costs or information given.