General Office Visit Consultation Agreement


  1. Nature of work performed:

    I understand that Sima is board certified homeopath, certified CEASE practitioner, GAPS certified practitioner and certified nutritional consultant who evaluates my entire condition based on homeopathic approach, and seeks to assist me to stimulate my body’s own healing mechanism with the use of homeopathic medications, diagnostic scanning health screening, supplements and nutrition appropriate for my health complaints. I understand that she is not a medical doctor, has not presented herself as such, and does not seek to diagnose, treat, or prescribe for disease, disorder or other pathological conditions. I understand that Sima Ash may also discuss with me the use of other complementary alternative medicine to improve my health, and that these are within her scope of practice to the extent that she incorporates them. I agree that I am interested in enhancing my own abilities to establish health in mind and body. I agree to consult a licensed physician for any medical concern that now exists or arises at any time during the term of this agreement, and to inform Sima Ash of my physician’s assessment in so far as it applies to my homeopathic case.

    Nature of work performed:
    Not sure where to start? This one hour general office consultation will be with Sima Ash to review your health concerns and to devise a treatment plan to achieve and preserve optimal health.

    Cost of General Office Visit:
    I agree to pay $300 for general office consultation.

    Rights and Responsibilities:
    Sima Ash of Sima Ash Wellness Center agrees to honor confidentiality and assures professional conduct and privacy regulations. Sima also agrees to elicit a history of indications relevant to my condition and discuss the results with me accordingly, I hereby acknowledge and retain these services at Sima Ash Wellness Center in order to maximize and preserve my health and well- being. I agree to provide a summary of medical and non-medical health care services which I have sought or am now considering, along with a complete description of my health history and current conditions. This agreement becomes part of my case records and Sima Ash wellness Center has the right to terminate treatment at any time.
  2. Name(*)
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  3. I Agree(*)
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  4. Date Submitted(*)

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  5. Verification(*)
    Verification
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