The Client Release Form

This form is provided so that patient becomes aware of the risks and legal rights they have. It is usually not a protection against any liability. It is a full disclosure to the client detailing what they are getting into and who their practitioner is, i.e. identifying him or her as a non-licensed practitioner, training, etc. 

All healthcare providers should use it and in some cases are required to use it. For instance, it is one of the requirements of the alternative practitioner to disclose the patient's bill of rights in Minnesota as of July 1st, 2001 because of their new Complementary and Alternative Health Care Freedom of Access bill Gov. Jesse Ventura signed into law. 

Please use this form as a way to educate and create an awareness of the responsibility the patient has with the homeopath. It was circulated by Susan Lavery, RSHom (NA) who came under legal attack by the state of Georgia in 1998. She now is doing well and lives in Asheville, North Carolina. You can contact her at her web site.

Sample Client Release Form

For all clients of homeopathy

Homeopathy by philosophy, science and practice does not diagnose or treat disease. The diagnosis and treatment of disease is solely within the license of the medical profession. IF YOU KNOW OR SUSPECT THAT YOU HAVE A CONDITION WHICH MAY WARRANT THE CARE OF A LICENSED MEDICAL PROFESSIONAL, YOU SHOULD SEE ONE AS SOON AS POSSIBLE.

Homeopathy treats underlying weaknesses and susceptibilities to the disease process by assessing through an interview process the state of one's mental, emotional and physical well being. Homeopathy is compatible with and never interferes with most orthodox, complementary or alternative medical treatments, so one may, depending upon circumstances, choose to utilize the benefits of more than one discipline.

I, ___________________________, understand that my homeopath, xxxxx xxxxx, is not a licensed practitioner in the state of xxxxx, nor is she a physician, naturopathic doctor or a nurse. I also understand that she is a highly skilled professional homeopath [and has acquired an accreditation of xxxxx from xxxxx. I am also aware she has received her training from various master clinicians in the U.S. and England.]

If you have any questions about the above, please feel free to discuss them with me before your first appointment or before your session. When you feel you fully understand the above, please sign this form at your first appointment.

I, ___________________________, as a mature adult, have read this disclosure and understand the above as well as the limitations of this service. I accept responsibility for my choice to seek for myself (or my legal ward, _______________________,) the consultative services of xxxxx xxxxx. I understand that my homeopath will not diagnose or treat disease in the process of homeopathic care. Furthermore, I understand that my homeopath will keep all of my records strictly confidential.  I give her permission to video or audio record my sessions for her personal use or for educational purposes.  I understand that my identity will be kept confidential if xxxxx xxxxx should need to consult another homeopath on my behalf or utilize my case in any way for teaching purposes.

I assume full responsibility for my choice of treatment and hold xxxxx xxxxx harmless.

Name (please print)________________________________

Signature________________________________

Date___________________

 

Witness____________________________________________

Date__________________

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