Please read the following declaration carefully and ask any questions you may have prior to your initial
consultation with your practitioner.
By making this appointment you declare that: You understand that the form of health care provided at this clinic is based on Naturopathic Medicine
and other supportive principles and practices.
Treatment Modalities include:
• You recognize that even the gentlest therapies may cause complications in certain
physiological conditions such as pregnancy, lactation, very young children, very elderly
patients, those on multiple medications, or those with specific diseases such as heart, liver,
kidney or diabetes.
• All information you have provided to your practitioner (Michelle Brown) about your current
health condition, both in your Client Intake Form and during any subsequent consultations, is
true and correct to the best of your knowledge.
• You agree to inform your practitioner (Michelle Brown) of any changes to your current
medical/health condition, including any new medications, herbs, vitamins, supplements etc you
are taking, any new injuries or diagnosed/undiagnosed medical conditions.
• If you are female, you agree to inform your practitioner immediately if you fall pregnant, suspect
that you are pregnant, plan to fall pregnant or if you are breastfeeding.
• You understand that a health record will be kept of the information disclosed in your
consultations and the treatments provided to you. This health record will be kept confidential
and will not be released to any other person without your written consent, unless required by
• You can look at your health record at any time and can request a copy of it as required.
• Your health record may be used for research and treatment purposes, but your identity will be
protected and kept confidential.
Information provided and treatments prescribed
By signing this form you declare that:
You understand that your practitioner Michelle Brown holds the following qualifications:
Advanced Diploma of Naturopathy, Nutritional Medicine and Herbal Medicine
• You understand that your practitioner Michelle Brown is not a medical doctor and that the
information provided to you is on no way intended as medical advice, or a substitute to medical
counselling and the information supplied should be used in conjunction with the guidance and
care of your physician.
• You are at liberty to to seek or continue medical care from a physician, or another health care
• No practitioner or employee of MB Naturopath has suggested or advised you to refrain from
seeking care from or following the directions of another health care provider.
• You understand your practitioner will answer all questions and explain all treatments to the best
of their ability and, as with any form of treatment, results and lack of side effects cannot be
• You do not expect your practitioner Michelle Brown to be able to anticipate all risks or
• You recognise that despite all precautions on behalf of your practitioner Michelle Brown there
are risks of side effects/complications/illness occurring as a consequence of the use or misuse
of the treatments prescribed by your practitioner Michelle Brown
• You expressly assume such risks and waive, relinquish and release any claim which you may
have against your practitioner Michelle Brown or their affiliates/employees/contractors as a
result of any future injury, illness, liability, loss or damage incurred in connection with, or as a
result of your use or misuse of prescribed treatments or advice.
Declaration and Consent
By making this appointment, you declare that:
• You have read and understand the above stated policies and information.
• You have received a full and complete explanation of the treatment and services that you may
receive at MB Naturopath Clinic.
• You hereby authorize and consent to treatment.
• You intend this consent form to cover the entire course of treatment you receive at MB
• You understand you may revoke this authorization for treatment at any time in writing.