The purpose of this form is to ensure that you, the patient, recognise your rights with respect to acceptance and refusal of the treatment you receive and your right to information about what is being offered.
Also that you can make as informed a decision as possible as to the information you disclose during the treatment sessions, and that you know for what purposes the information may be used.
You have a right to understand the treatment you receive, to choose, at all stages, whether or not to receive the treatment and to know the standards of confidentiality maintained by those providing your care.
By signing the form you are agreeing to the following:
- I know that I am being treated by Paul Blacker (the practitioner) and that he is taking responsibility for my treatment.
- I understand that any information I give to him will be held in strict professional confidence and used only for treatment purposes.
- I know that I may ask for any information to enable me to understand the treatment I am being offered, and that my practitioner will inform me if a new treatment is to be used.
- I know that at any stage I may withdraw my consent for a given procedure or for further treatment without the need to explain myself.
- Any personal information provided by myself will be sensitively disclosed to the practitioner in order to ensure safe and satisfactory treatment.
- If my case is used for research purposes I know that identification will be removed and that my case will be referred to in non-specific and general terms.
- If I have an appointment at the Clinic, I am aware that if I do not turn up for my treatment or cancel within 24 hours of the appointment I may be liable to pay the full fees for the appointment I have missed.
- I understand that if I am deemed to be under the influence of alcohol or illegal drugs I may be refused treatment.
- I understand that the practitioner has the right to refuse me treatment if it is felt that my medical condition requires referral.
I confirm that I have read and understand the above. I have had my treatment explained to me, I understand what procedures will be used and I give my consent for this to happen.
Print Name: ___________________________________________________