INFORMED CONSENT - GENERAL AND MEDICAL RELEASE
[Dr. Cousens’ Tree of Life Holistic Health Practice, 686 Harshaw Road, Patagonia, AZ 85624]
All clients agree to disclose all significant health issues on the Health Intake Form or discussed with the medical staff prior to first medical appointment. If significant health issues are discovered by the medical staff that were not disclosed on the Health Intake Form, or disclosed to the medical staff prior to arrival, the Tree of Life Holistic Health Practice reserves the right to dismiss patients without refund.
Participating in any activity on the Tree of Life property carries some risk, including but not limited to the risks listed below. I choose to participate in any TOL activity with awareness of these potentials, and I agree to be responsible for my own safety.
• Therapeutic Procedures: There may be risks involved in any therapeutic procedure offered at the Tree of Life including but not limited to: Nutritional and Medicinal Supplementation, Fasting, Auricular Acupuncture, Vitamin and Mineral Shots, Homeopathic Vaccinations, Scar Injections, Liver Gall Bladder Flushes, and Cellular Detoxification Bodywork Treatments. I also understand the risks involved in this process and agree to the testing, counseling, and other therapeutic procedures.*
• The Tree of Life, under Gabriel Cousens, MD, MD(H), has developed a cutting edge diabetes program for Type 2 diabetics. Any program of this nature has a certain risk associated with it, including diabetic ketoacidosis for Type 1 diabetics, which may require hospitalization, or allergic reactions to prescribed supplements. I understand these risks and agree to participate in the program regardless of the risks.
• Dr. Cousens’ Tree of Life Holistic Health Practice offers no guarantees in the reversal of diabetes or any other health condition that may be supported by the Tree of Life Lifestyle. We offer no guarantee of degree of healing.
• Patients are responsible for following the guidelines of their healing plans. I understand that if I choose not to follow the plan, I cannot expect results. I agree to the medical policy found on the website (www.drcousens.com) and in the attached information.
• I understand I may receive a doctor prescribed supplement program following my evaluation, which will be tailored to my individual needs. I am aware that purchasing these supplements is optional, but strongly recommended for my health and may cost an additional $3000 or more depending on my needs. I am also aware that these supplemental needs may shift as my body is brought back into a balanced state.
• I understand that the physician may require additional time with me—up to 4 hours—depending on my individual health. I understand that I am charged for the amount of time I am with the physician, and may inform the physician at the beginning of my consultation what my budget allows for. A standard appointment is 2.5 hours. If an appointment runs for 3 hours, I will be charged for 3 hours.
• I am aware of and understand the rates and fees that apply to the services and treatments I may choose to partake in during my visit at Dr. Cousens’ Tree of Life Health Practice, which are outlined in the Important Policies document*.
• I understand payment for any products or services will be collected or charged to my credit card as follows:
Products in the store or dispensary: at time of purchase
Medical services: at time of service
• I agree to hold the Tree of Life not responsible for lost or stolen property and/or damage incurred to my vehicle while on Tree of Life property.
• I understand that any services or products that I purchase, that are not charged at the time when due (see above), will be charged at a later date.
• I agree to give 30 days notice of cancellation for appointments with Dr. Cousens, 48-hour for other medical services.
• I understand and accept the Tree of Life Cancellation Policy.*
REFUND POLICY: Cancellations are refunded in full, less a $200 processing fee, with notice more than 30 day prior to your check-in day. Cancellations within 30 days prior to a scheduled appointment are not refunded.
INSURANCE POLICY: Upon your request, we will provide the appropriate invoice for submitting to your insurance company. We do not bill insurance companies directly. Although Dr. Cousens is an M.D. in California, he is licensed in the state of Arizona as a Homeopathic Physician. Medicare does not reimburse clients for services rendered by any homeopathic physician. Other insurance companies may reimburse in part or in full. We urge you to please check with your insurance company before your appointment with the doctor. For billing questions, please call our office.
I hereby agree to indemnify and hold harmless Dr. Cousens’ Tree of Life Holistic Health Practice and the Tree of Life Foundation, its agents, officers, and employees from all claims or demands of any sort which arise out of or are caused by my participation while at the Tree of Life Health Practice property in Patagonia, or at any other location where an event is being held that is sponsored by the Tree of Life Holistic Health Practice.
I waive and release the above mentioned from all liabilities, claims or demands of any sort that I may have for personal injuries or for injuries to property arising out of my participation at Dr. Cousens’ Tree of Life Holistic Health Practice. I also hereby consent to and permit emergency treatment in the event of illness or injury while at Dr. Cousens’ Tree of Life Holistic Health Practice.
BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.