Healthy living
starts from within!

Healthy living
starts from within!

Patient Consent

Patient Consent Form

Name(Required)
Height in CM
Your weight in Kilograms

I, the above patient, hold harmless and herby indemnify Sister Jackie of the following terms and conditions:

  1. I shall not hold Sister Jackie liable for any loss, damage or harm to my property or person when attending my appointment.
  2. It is my responsibility to disclose any medical condition, diagnosis or treatments that I have had.
  3. It is the Sister Jackie duty to inform me of relevant contra indications and expected benefits of the treatment / procedure recommended to me. Once I have been so informed, and in the absence of any further questions or objections from me, Sister Jackie shall be entitled to proceed with such treatment / procedure.
  4. I understand that Sister Jackie might suggest certain unregistered medicines. I further understand that in doing so, Sister Jackie is neither breaching any law nor compromising my safety, but rather endeavouring to provide me with the most comprehensive and affective choice treatment available at the time.
  5. Certain treatments suggested by Sister Jackie are widely seen as alternative / integrative / complementary or conventional medicine. Whilst these treatments are very advanced, they are by no means guaranteed to adequately treat or cure any condition or diseases.
  6. Irrespective as to whether any treatment recommended to me is “conventional” or is deemed “alternative / integrative / complementary”, I hereby indemnify Sister Jackie from the consequences, medical or otherwise, should such treatment be found to be unsuccessful, whether in part or entirely.
  7. I acknowledge that certain conditions that I may have, whether latent (not apparent at face value) or patent (known to Sister Jackie and myself) may react either positively or negatively to the treatment recommended to me. I hereby take it upon myself, to ask Sister Jackie about the known risks associated with my relevant treatments.
  8. Consequently, by furnishing Sister Jackie with my informed consent for any such treatment, I hereby indemnify and hold harmless Sister Jackie, against any harm suffered by me subsequent to the implementation of such treatment, irrespective as to whether such treatment is the direct or indirect cause thereof.
  9. I understand that all information discussed in private with Sister Jackie will be kept confidential, except:
    • if the patient (I) share my condition or illness with persons in the Shop (Emagenes) this will have been shared willingly and Sister Jackie cannot be held responsible therefor.
    • Keep in mind that any criminal acts mentioned to Sister Jackie, by law should be brought to the attention of law enforcement. (This is not breach confidentiality)
    • If my condition needs to be referred to another practitioner. I understand that information shared in consultation will be disclosed to another practitioner.
  10. I will contact Sister Jackie if acute symptoms have not cleared up within 72hours.
  11. Appointment costs: First visit R400, Appointments after 6 months R400. Follow up appointments within 6 months R250.
  12. I have been given the opportunity to ask questions about the procedures indicated and I have sufficient information to give my consent.
  13. I have read and understand the Indemnity I have signed.

Consent(Required)