Consent to Treatment

This consultation is for informational and / or educational purposes only and shall not be construed as legal or medical advice. Consultation Services include in person visits and/or any virtual sessions, email, text or phone correspondence and any documents provided therewith, and are not intended and shall not be construed to be the practice of medicine. There is no doctor-patient relationship expressed or implied. The questions and topics discussed are not intended to be used to diagnose, treat, cure or prevent any disease or concern. There is no guarantee of outcome based on how you intend to use or do use the information provided. The information provided is the best available information, given what is known at the time of the consultation. You assume all risk and responsibility for using this information.

Please consult with your healthcare practitioner before implementing any information or advice provided by Pailin Brzeski of Form and Heal, who cannot serve as your physician, primary care provider, or specialty care provider, therefore we cannot be listed as such on any medical paperwork or to healthcare agencies and insurance providers.

You are responsible for payment prior to the time of your appointment (via a monthly membership in good standing or pre-payment for your one-time appointment fee).

All cancellations must be made at least 24 hours prior to your appointment, or the full fee will be due. Additional charges may apply for repeat last-minute cancellations (upon prior notice).

Telehealth Consent

I understand that my health and wellness provider, Form & Heal, wishes me to have a telehealth consultation.

This means that through an interactive video connection, I will be able to consult with the above-named provider about my health and wellness concerns. My provider has explained to me how telehealth will be used to do such consultation and how else we will use telehealth to connect while working together, using ZOOM, WHATSAPP, MESSENGER and EMAIL as required/appropriate.

I understand there are potential risks with this technology:

• The video connection may not work or it may stop working during the consultation.
• The video picture or information transmitted may not be clear enough to be useful for the consultation.

The benefits of a telehealth consultation are:

• I do not need to travel to the consult location.
• I have access to a specialist through this consultation.

I also understand other individuals may need to use the Healthie telehealth platform and that they will take reasonable steps to maintain confidentiality of the information obtained. I have read this document and understand the risk and benefits of the telehealth consultation and have had my questions regarding the procedure explained and I hereby consent to participate in telehealth sessions under the conditions described in this document.

Refund and Cancellation Policy

Refund Policy

Once you have selected and paid for your service, it is not possible to provide a refund, regardless of whether you have selected a membership service or a pay per appointment service. You may however cancel your monthly membership at any time, with the understanding that there will be no refund for any unused services. Initial membership subscriptions are subject to a minimum 6-month subscription. Arrangements for early termination may be made by contacting pailin@formandheal.com.

Appointment Cancellation and Rescheduling Policy

If you must cancel or reschedule your appointment, kindly give at least 24 hours notice. This notice must be by email or text, and be sent 24 hours or more prior to the start of your scheduled appointment time. Please give your calendar a thorough look before scheduling, and reserve rescheduling for emergencies only.

Although appointments may be cancelled at any time, rights are reserved to charge a cancellation fee of up to £50 for any appointments cancelled less than 24 hours before your scheduled appointment time. It is understood that extenuating circumstances may apply, these will be carefully considered prior to charging a cancellation fee. This policy is to ensure efficient scheduling for all clients. Thank you!