Treatment agreement

Practice Details
Yosay Acupuncture
AGB code: 90114082
Chamber of Commerce number: 34393878
Member NVA - Member KAB

When booking a treatment, the client declares that he/she wishes to be treated by the practitioner for the reduction of the main complaint(s) indicated and any related complaints and complaints that may arise in the course of the treatment process.

• Along with this treatment agreement, I have taken prior notice of:
  The General Terms and Conditions of the practice. I agree to these terms and conditions;
  The Privacy Statement. I am aware that my personal and medical data will be stored and processed in a secure manner. This is necessary for the execution of the treatment agreement.
  I consent to the sharing of my file data in the following cases:
  Notice of arrival to my general practitioner/treating specialist;
  Progress or final report to my GP/treating specialist;
  Consultation with colleagues by the practitioner, if deemed necessary. I will always remain anonymous.
  Discussion of my case in an anonymous form with trainees of the practice;
  Use as an anonymous case for teaching purposes.

Other:
I am aware that the treatment offered is complementary to mainstream medicine;
I will consult my primary care physician or treating specialist if my health situation requires it;
I am aware that I am free to terminate the treatment agreement;

Only if client is younger than 16 years old, this form should be signed by parent/guardian.
Client is younger than 16 years old; consent for treatment is given by signature of:
the custodial parent(s), namely:
the guardian, namely:

Signature(s):

Place: Date: