TERMS OF ENGAGEMENT & CONSENT
Incl. Case study consent between the Dr. Suraya Diaz/practitioner and client.
Good nutrition supports the body’s natural defences and resistance. However, no claim can be made about the efficacy of any naturopathic nutritional advice.
Please read the following information carefully.
What can I expect?
You will be attending the Herbal Medicine/Nutrition Clinic online/skype/ phone or in person.
Dr. Suraya Diaz will be your point of contact and will take your case history and subsequently design an individualized program for you.
What’s going to happen?
Dr. Suraya Diaz will take your case history, so you will be asked a wide range of questions. You may also have an examination performed if appropriate. This may range from the type of examination that your doctor may perform such as having your blood pressure taken to having your tongue and pulse examined. All the information provided and discussed will be strictly confidential.
Dr. Suraya Diaz is a highly trained experienced herbalist, nutritionist and naturopath and will oversee and maintain responsibility for your consultation and Herbal/Nutritional/Naturopathic treatment. Whilst every care is taken to provide you with the highest level of care and security, Herbal Medicine/Nutrition/Naturopathy, as any medicines can cause reactions which differ from person to person. Therefore, if you have ANY concerns or queries please do not hesitate to contact Dr. Suraya Diaz.
You are responsible for contacting your GP or specialist about any health concerns you may have. Please advise your GP of the Herbal Medicine/Nutritional/Naturopathic protocol you will be following. Please also inform Dr. Suraya Diaz about any other complementary medicine practitioners you are consulting. It is important that you tell Dr. Suraya Diaz about any medical diagnosis you have received, or any prescription medication, or Herbal Medicine or food supplements or over the counter medication you are taking, as it may affect the Herbal Medicine/Nutritional/Naturopathic program. If you are unclear about any part of your program, then you should contact Dr. Suraya Diaz immediately for clarification. Dr. Suraya Diaz will then respond to you. You are responsible to follow Dr. Suraya Diaz instructions precisely and respective outcome. Your Herbal Medicine program will have a time frame and you should not continue with recommendations outside of this unless agreed by Dr. Suraya Diaz who is your Herbal Medicine/Nutrition/Naturopathy practitioner. This is to avoid any adverse reactions. Please report any concerns about your program to Dr. Suraya Diaz.
I understand the above and agree that our professional relationship will be based on the above content of this document. I further understand that Dr. Suraya Diaz will design a therapeutic individualized program for myself based in the information that I provided. I understand that I am responsible to follow Dr. Suraya Diaz Herbal/Nutritional/ Naturopathic program and respective outcomes. I understand that I should contact Dr. Suraya Diaz if I experience new symptoms or if I have any queries regarding the treatment program. I understand that all the information that I provided will be strictly confidential and that my case may written up as a case study with any personal identifiable details being removed from the written submission. I understand that all the information provided in Dr. Suraya Diaz Clinic will be strictly confidential. I understand that this consent form will be submitted to the Dr. Suraya Diaz Clinic and that I may be contacted for verification.
With these understandings, I consent to participate as a client in the Dr. Suraya Diaz Clinic.