Consent for Continued Treatment at NPSA | Natural Pain Solutions Australia

Please complete to consent to continuing treatment with Scott Hankinson. Thank you for your understanding!

Name*

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Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are you a Parent/Guardian filling in this form on the client's behalf?*

Name of Parent/Guardian (if applicable)

Relationship to Dependent

Email (please use the same email as you normally use for correspondence with NPSA)*

COVID-19 and Vaccination:

We respect all vaccination choices, and ask that you respect ours too. Please be aware that you are visiting a natural health clinic where practitioners and staff have a very different concept and philosophy of health and immunity to western medicine. It therefore is very important you are aware of the following when choosing to come to our centre:

We strongly believe we have a duty of care to ALL clients and will not withhold treatment on the basis of race, age, gender, vaccination status or any other factor. Additionally, we oppose discrimination for any reason on clinic premises and we ask that you join our culture whilst on the premises. If you feel unable to do this, we respectfully suggest you find a different practitioner.

We value privacy of medical/health information and decisions, and we ask that you do the same whilst on the premises. It is widely understood that COVID-19/SARS-Cov2 can be contracted and transmitted by both vaccinated and unvaccinated individuals; therefore another individual's vaccination status has no bearing upon one's own health and wellbeing. This means questions to other clients and staff about their vaccination status are not relevant.

Due to medical exemptions or personal choice, there are likely to be individuals on site, both practitioners and clients, who are unvaccinated for a variety of diseases including COVID-19/SARS-Cov2. A reminder again here that you can catch COVID-19 from both vaccinated and unvaccinated individuals, and whether you are vaccinated or not you can transmit COVID-19. The health advantage to being vaccinated occurs purely on an individual basis, in that it may decrease your personal likelihood of severe disease and hospitalisation.

Please be assured we follow Covidsafe practices, and in addition we use anti-viral and anti-bacterial air filters in reception and the large treatment centre, to help prevent transmission of viral particles from both vaccinated and unvaccinated people.

If you have any questions regarding these matters, please do not hesitate to discuss them with us.

In signing and submitting this form, I understand and acknowledge the following, where ‘Natural Pain Solutions’ refers to Natural Pain Solutions Australia, its staff and corporate or trust entities, including associated directors and shareholders, with legal ownership or liability, and where the terms ‘I’, ‘my’ and ‘myself’ refers to me, any of my dependents and any support persons that accompany me on Natural Pain Solutions' premises.

1. I understand it is possible for me to contract COVID-19/ SARS-Cov2 from both vaccinated and unvaccinated individuals.I choose of my own free will to accept all risks and consequences, whether real or assumed, when attending appointments at the premises, and I will not hold Natural Pain Solutions liable in the event of contracting any disease on the premises. I understand I have the option of online consultations if I choose not to come to the premises.

2. If I have had, or will have, a COVID-19 vaccination or booster, I am aware that adverse reactions and, rarely, injury or death may result, at any point in the immediate or distant future. If any of these occurrences happen on clinic premises, I will not hold Natural Pain Solutions responsible.

3. I am aware that the interaction between COVID-19 vaccines and natural medicines and therapies is unknown, and so there is a possibility of unforeseen consequences. I undertake treatment at Natural Pain Solutions willingly in this knowledge, and I will not hold Natural Pain Solutions Australia responsible for any medical complications, injury or death suffered either directly or indirectly from using natural medicines or therapies in combination with having a COVID-19 vaccine or booster.

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Today's Date*

Natural Pain Solutions is a Unity Community.
Outside of a consulting room, your vaccination status is #notourbusiness.

Additional Consent Form for Existing Clients