(Please read carefully)
Thank you for choosing Natural Anti-Ageing Australia (NAA) and its HCG Protocol for weight loss, where we are committed to providing the best medical care possible to our patients. Please be aware that the payment of your services is considered part of your treatment. The following statement explains our financial policy. Your payment is due once you have agreed to join the program.
We accept cash, Visa, Master Card and EFTPOS.
If at any time after payment for your treatment you decide to either not attend your scheduled appointments or delay your commencement to such a degree that the product is no longer viable (HCG is a perishable pharmaceutical product that has a limited lifespan that can effect its efficacy) – you understand that your payment may be forfeited.
By submitting this form you acknowledge that you are financially responsible for charges incurred during treatment under the care of NAA.
SCHEDULING AND FEES
24 (business) hour prior cancellation notice is required for all follow-up visits.
A $70 cancellation fee may be charged if this is not given and appointment time forfeited.
We do not double book appointments and these fees and/or deposits are charged for the
- Inability to schedule another patient in that time frame
- Paperwork produced for the visit
- Chart review in preparation for your visit
- E-mails sent to you
- Phone calls reminding you of the appointment
- Staffing costs for the aforementioned required preparation
We appreciate your consideration when making your appointments. We also do understand that at times there will be emergencies that do not allow for the 24 hour time frame and as such will review these cases on an individual basis.
VISIT REQUIREMENTS FOR HCG PROTOCOL WEIGHT LOSS PROGRAM
- Initial Visit. Your Initial Visit will start your program, which may or may not be on the same day that you came in to learn about the program and what is offered. You will have a medical examination and you will receive your package of information, supplements you will need for the first week of the program (Stage I pre-treatment).
- Follow up Appointments: Your 3 follow up appointments will be set up when you come in for your initial visit. They will be set for specific times during your progression in your program. These are usually Day 1, day 7 or 14, and day 21 of Stage II (the active hCG Cycle). These scheduled appointments will need to be adhered to so as not to interfere with your medical supervision. Should you need to cancel you will be required to give a 24 hour notice and your reschedule will be set within 5 business days of the time periods being supervised. Visit requirements are the minimum amount of visits that are necessary to follow your medical treatment. Please remember that any time you would like to schedule a visit you may (there will be an additional cost for visits outside of the packaged price). Your health concerns are our main priority. If you are unable to attend the minimum amount of visits for treatment you are not a good candidate for this therapy. Medical follow up on any treatment is always necessary and this form of therapy requires you to be dedicated to your health concerns. While this office has been formed as a business and has priced itself as competitively as possible it is also a center for healing and education, so we are not prepared to deliver substandard care or risk your health.
I agree that I have read the minimum required office visit schedule. I realise that if I am unable to follow the protocol of these visits that I may be released as a patient under NAA’s care and that there are no refunds for packages, products or Iab kits after they have been removed from the office. All supplements, products and lab kits are sealed and or involve perishable fluids and once they have left the office are considered unsuitable for resale and non-sterile (this no return policy on products, packages and lab kits is non-negotiable). Should I voluntarily choose and or be discontinued from this treatment I understand that if I resume treatment it will be set up as a new package purchase and all initial workups shall be required as with any brand new patient. I understand that this information is not a contractual agreement (regarding office visits) it is only meant to make my decision to pursue HCG Protocol for weight loss and is a fully informed decision on my part.
CONSENT TO TREAT
I consent to the use and or disclosure of my protected health information for purposes of diagnosing or providing treatment to me or obtaining payment for my health care bills. I consent to treatment and understand that my physicianis a licensed Medical Physician. I further consent to information relating to my weight loss results to be used as part of aggregated data to assist with research and support materials. It is understood that none of my personal information will be utilised apart from statistics such as age, sex, weight, height, fat percentage and other measurements, etc.
I understand that if I am unable to attend follow up visits within the regimen prescribed, that I may be released as a patient under care as follow up is an integral part of this therapy. In so being truant in my follow-up Iacknowledge that if I develop side effects or complications whilst on the program I release from all liability, HCG Protocol and its employees/physicians. I understand that all my specific personal medical information will be kept confidential and private.
DURING THE HCG TREATMENT
If you have any questions regarding your treatment, you are encouraged and expected to ask them.
Furthermore, the patient agrees to submit an accurately completed medical history form to be filled out accurately and completely and hereby acknowledges that failure to provide truthful, accurate and complete information could result in inappropriate treatment that would increase the risk of complications.
Patient hereby authorises HCG Protocol or its staff member to obtain health information necessary for treatment to include consent for information to be obtained on their behalf from medical laboratories diagnostic testing physicians and dispensing pharmacies, as may be indicated in the course of such treatment.
Patient covenants and agrees to comply with the method of instructions, treatment, dosage schedules prescribed by the Physician, to immediately cease any medical treatment prescribed by the physician in the event of any adverse reaction or side effect arising from the prescribed treatment and to immediately provide HCG Protocol with notice of any such adverse reaction or side effect.
In the event of any adverse reaction or side effect arising from prescribed treatment, Patient agrees to provide immediate written notice. Although longitudinal studies demonstrating the benefits of this type of treatment available through hormone replacement therapy have been conducted over the past 40 years,, the Patient acknowledges that he/she has been made aware that at present there still exists conflicting data re the efficacy of hCG therapy in weight loss, and that amongst physicians there is still argument at to the exact role hCG therapy holds in the management of weight loss.
The patient also acknowledges that NAA have made no guarantees or warrantees with respect to 1) amount of weight that will be lost, 2)associated diagnostic testing, 3)analysis of test results, 4) examination of medical history or treatments. The patient is aware of the potential side effects of hCG therapy, as well as adverse effects of rapid weight loss. The patient is also aware that individual results on hCG therapy may vary greatly.Patient agrees that they have been advised of and are aware of the nature, risk and possible
alternative methods of treatment, including possible consequences and complications involved in hCG weight loss. Patient acknowledges the hCG Protocol for weight loss involves the use of a medical drug. Nonetheless Patient consents to such care and treatment and executes this agreement with complete, informed understanding of such therapy for the purpose of authorising physician to prescribe such treatment to relative body ailments, obesity and unhealthy weight levels and attempts to enhance Patients physical condition and health. Patient agrees that if they become pregnant or decide to pursue becoming pregnant to stop the program and inform the treating Physician of this. Patient further acknowledges that the method of medical treatment offered by NAA and Physicians are not accompanied by any claims, guarantees, promises or warranties whatsoever.
This agreement shall be governed, construed and enforced in accordance with the laws of the state of VICTORIA, applicable to agreements made and to be performed entirely within such state, without regard to any conflict in law. Any disputes arising out of, in connection with or with respect to the Agreement shall be adjudicated in a court.
Patient covenants and agrees to indemnify, defend, protect and hold harmless NAA and their respective offices, directors, employees, stock holders, assigns, successors and affiliates (Indemnified parties) from, against and in respect of all liabilities, losses, claims, damages whether direct and proximate or indirect, incidental, or consequential, special damages, punitive damages, causes of action, lawsuits, administrative proceedings, investigations, demands judgments, settlement payments, deficiencies, penalties, fines, interest and costs and expenses suffered, sustained incurred or paid by the indemnified parties in connection with resulting from or arising out of directly or indirectly NAA or physician’s rendering of medical care, services, advice, consultation and /or treatment.
If I fail to keep my designated appointments and do not make arrangements for alternate timely follow up, I understand that NAA may terminate my course of treatment with this Weight loss. therapy. Additionally, I understand that if it is determined that I am using the prescribed medication in a manner not consistent with the way NAA staff has instructed me, that my prescription may similarly be terminated.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
NAA is required by law to maintain the privacy of certain health care information about our patients. The law also requires health care providers to give you a Notice like this one and to follow its standards.
As a part of our day-to-day activities, we may need to use and disclose (share) your protected health care information for several purposes without first getting your written approval. Those purposes include:
- Your treatment. For example, we might discuss your condition and medications with your pharmacist.
- Payment for your treatment. For example, we may need to discuss your condition and the treatments we provided to you with your insurance company should they require medical information to process the claims you file.
- Staff must discuss your condition in order to provide you with proper treatment.
- We may contact you based upon your protected health care information. For example, calling to arrange your appointments, provide you with information about new medications, treatments, benefits and services that are available to you and via e-mail.
No other uses and disclosures of your protected health care information will occur without your written authorisation. And, if you sign such an authorisation, you have the right to cancel it at any time.
I agree to hold NAA harmless for the development of any of the above health risks and/or side effects that may be associated with this Weight loss program.
No other uses and disclosure of your protected health care information will occur without your written authorisation and if you sign such authorisation, you have the right to cancel it at any time.