Foundation Of Health Consent Form



In accordance with the Federal Government’s Personal Information Protection and Electronic Documents Act (PIPEDA), Foundation of Health Clinic needs your informed consent to provide assessment and treatment services to you, and to collect and use your personal information. We want you to understand the services we provide, the cost involved and what we may do with your personal information obtained about you.


I voluntarily consent to medical treatment provided by Foundation of Health Clinic and associated homeopathic doctors, clinicians and other personnel. I am aware that the practice of medicine (be it in homeopathy of western medicine) is not an exact science and I acknowledge that no guarantees have bene made as to the result of treatment or examinations.

I agree to participate in assessments and treatments given by the treating provider. I understand that it will involve my active participation in treatment and will comply with the provider’s recommendation in order to enhance my recovery. I acknowledge that my provider has given me information that is pertinent to my treatment, including the possible risks and side effects of the proposed treatment. I understand the consequence of having and not having treatment. I understand that the assessment and treatment services I undergo may be administered by the treating provider, and by the support staff under the supervision of the treating provider.


I agree that I have been informed of the costs of the assessment and the treatments/services provided to me. I understand that I am responsible for paying in full, the balance of any amounts. I understand that Foundation of Health Clinic may request of me a credit card imprint as security for payment of services. Payments may be done by cash, check interact,Master Cardand Visa. Any returned checks will be processed $35.00 per returned check.

After hour office care is provided for patients who are on a current homeopathic program/treatment. For those who are not a fee of $50.00 shall be billed automatically (as this is an elective service). By signing and dating this form, I am indication that I have been informed by Foundation of Health Clinic or other related organization that the services I will receive today may not be covered by my insurance plan.


I am aware that consultation fee charged by Foundation of Health Clinic are non-refundable. Furthermore, I am aware that Foundation of Health Clinic does not offer refunds on homeopathic medicines (whether unsealed or sealed) and other products sold at Foundation of Health Clinic.


Our goal is to provide quality health care in a timely manner. In order to do so we have had to implement an appointment/cancellation policy. The policy enables us to better utilize available appointments for our patients in need of care.

Scheduled Appointments

For a scheduled appointment please call 403-265-9730. We encourage that you schedule appointments for preventative health visits, chronic medical conditions and general health maintenance.

Cancellation of an Appointment

In order to be respectful of the health needs of others please be courteous and call the clinic promptly if you are unable to attend an appointment. This time will be reallocated to someone who is in urgent need of treatment. This is how we can best serve the needs of individuals and families.

If it is necessary to cancel your scheduled appointment, we require that you call by 10 a.m. one (1) working day in advance. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to timely medical care.

How to Cancel Your Appointment

To cancel appointments please call 403-265-9730. If you do not reach the receptionist you may leave a detailed message on the voice mail. You may not cancel via email.

Late Cancellations

Late cancellations will be considered as a “no show”.

No Show Policy

A “no show” is someone who misses an appointment without cancelling it by 10 a.m. one (1) working day in advance. No-shows inconvenience those individuals who need access to care in a timely manner.

A failure to present at the time of a scheduled appointment will be recorded in the patients’ chart as a “no show”. An administrative fee will be waived for the first “no show” and $75.00 for subsequent “no shows” will be billed to the patient’s account or sent to the patient’s home. The patient will be sent a letter alerting them to the fact that they have failed to show up for an appointment and did not cancel the appointment by 10 a.m. (1) working day in advance. A copy of the letter will be placed in the patient file. Three “no shows” will result in the temporary suspension of services. In order to reinstate services, the patient will be required to meet with the Clinic Director to evaluate the situation.

Acute Consultations

We realized that illnesses and accidents often occur unexpectedly. In an effort to provide the convenience of timely healthcare we offer acute consultations. Acute consultations are for urgent and unpredictable medical care. General exams, renewal of homeopathic programs, and routine care are not appropriate to be seen for acute consultations. The acute consultation will only manage the presenting problem. For other medical concerns a booked appointment will be provided.

All emergencies will be given priority.

Life threatening emergencies

Always call 911 immediately in case of a life-threatening emergency. Provide the following information: Your name Your location Nature of the emergency


Foundation of Health Clinic is responsible for the under its control, had developed a Privacy Policy, and has appointed a Privacy Officer to ensure that it complies with this Privacy Policy and all applicable privacy information affecting Foundation of Health Clinic’s use of your personal information. Personal information that Foundation of Health Clinic collects, retains, uses and discloses may include without limitation, your name, age, contact information, occupational information, personal health information, medical history, and other information deemed necessary to fulfill the following for purposes:

1. To provide assessment and treatment services

2. To comply with The requirement of professional regulatory bodies, including file audits.

3. To contact you about services you have received or services we’re offering. This may include (without limitation); follow-up calls or appointment reminders, newsletters, notices of promotions and special events.

4. To invoice you directly for services provided, and the process payment for those services.

5. To provide Third Party Payers, Physicians and Legal Counsel with progress report / assessment findings, resulting from services provided to you.

6. To market services provided by Foundation of Health Clinic and its associates.

7. To determine best clinical practices, and ensure quality of service by staff of Foundation of Health Clinic.

8. To store information on behalf of Service Providers or Third Party Payers.

I understand that Foundation of Health Clinic may use, share, disclose and retain my personal information, in order to fulfill the purposes noted above, or where otherwise permitted by law. I understand that Foundation of Health Clinic collects, uses and discloses only personal information required to fulfill those purposes. I understand that Foundation of Health Clinic shall not use my personal information for purposes other than those without my consent.

I understand Foundation of Health Clinic strives to ensure that my personal information is as accurate as possible and that Foundation of Health Clinic has in place security safeguards desired to protect against loss, theft, or unauthorized access or disclosure of my personal information.

I understand that I may request Foundation of Health Clinic to allow me to review my personal information, and that I may contact and discuss with Foundation of Health Clinic’s compliance with its Privacy Policy and applicable Privacy legislation.

I have read and understand this consent form. I hereby give Foundation of Health Clinic permission and consent to maintain personal information already of file with Foundation of Health Clinic, pursuant to its Privacy Policy, and to assign Foundation of Health Clinic and its agents, past, present, and future collections, uses, and disclosures of my personal information for the purposes set out in the Foundation of Health Clinic Privacy Policy. I understand that my consent may be revoked in writing.

I understand the consent for treatment, financial responsibility, cancellation and privacy policy will be from the date of signature and can only be revoked upon written notice. By, signing below, I acknowledge that this consent form has been read in full and explained, as necessary. I have read or have had read to me this consent form. I understand and agree to its contents.

Patient Name: ______________________________

Patient’s Signature: _________________________

Date: _________________________

Witness Name: ______________________________

Witness’s Signature: _________________________

Date: _________________________


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With Dr. Nielsen’s help, (I am) coping much easier with life and feeling truly alive again. I am feeling much stronger, more confident and happier than I have in at least 10 years, and remain blissfully drug free! -Shannon E.