Informed Consent and Declaration
I hereby give my consent to an integrative, biological, and medical assessment and treatment (s):
Treatments may utilize such substances as herbs, vitamins, minerals and various other therapeutic modalities, which will be determined by the consultants of The Healing Hills Naturopathy & wellness Pvt Ltd. Assessment findings and treatment plans have been discussed in full with me for myself /spouse/children/parents (please strike off the irrelevant).
Further, I have been informed and explained about the expenses of the treatment plan or service chosen by me for myself / spouse / children / parents (please strike off the irrelevant). Also, I have been apprised of the alternative options of the treatment or service available in the health industry for myself/spouse/children/parents (please strike off the irrelevant).
I am responsible for the decision to seek a therapeutic program that includes the physical, psychological, environmental, and spiritual aspects of my / my spouse’s / my children’s / my parent’s (please strike off the irrelevant) wellness need (s) / complaints(s).
As a further inducement to The Healing Hills Naturopathy & wellness Pvt Ltd centre to provide treatment / services for myself / my spouse / my children / my parents (please strike off the irrelevant), I hereby waive any claims and demands that I might now or hereafter having against the The Healing Hills Naturopathy & wellness Pvt Ltd, the Holding Company (s), their owners, employees, therapists, doctors, suppliers, vendors, associates, agents and consultants that may arise, or be deemed to arise, from treatment / service at The Healing Hills Naturopathy & wellness Pvt Ltd.
Also, I hereby release The Healing Hills Naturopathy & wellness Pvt Ltd, The Holding Company(s), their owners, employees, therapists, doctors, suppliers, vendors, associates, agents and consultants from any and all liability of whatsoever kind or nature arising out of or in any way their relating to the treatment / service I receive for myself / my spouse / my children / my parents (please strike off the irrelevant) at The Healing Hills Naturopathy & wellness Pvt Ltd.
The medical consultation records of mine / my spouse’s / my children’s / my parent’s (please strike off the irrelevant) are strictly confidential. They are intended to be read only by myself and the The Healing Hills Naturopathy & wellness Pvt Ltd staff. These records will not be transmitted to anyone else without my written permission.
I certify that all the facts related to my / my spouse / my children / my parent’s (please strike off the irrelevant) lifestyle, medical history and consultation to be true and correct.
Regardless of the jurisdiction in which this Declaration is signed by me for myself / my spouse / my children / my parent (please strike off the irrelevant), it shall be deemed to have been signed by me in India. Any dispute arising from, out of or as a consequence of this Declaration or the treatment / service given by the The Healing Hills Naturopathy & wellness Pvt Ltd shall be subject to the laws of India and this Declaration shall be interpreted and construed in accordance with the laws of that jurisdiction. I hereby submit to the jurisdiction of the courts in Coimbatore district, Tamilnadu, India only for resolution of any dispute arising out of or relating to this Declaration and the treatment / service performed by the The Healing Hills Naturopathy & wellness Pvt Ltd.
This Declaration was given to me, read by me and signed by me for this treatment/service for myself / my spouse / my children / my parents (please strike off the irrelevant)