Koru Naturopathic Assessment

Accuracy of Information:
By signing this form, I certify that the medical information I provide is correct to my knowledge.

Privacy and Sharing of Information:
By signing this form, I authorize Koru Nutrition's ND, and Koru Nutrition Inc. to collect my personal and medical information. In addition, I authorize Koru Nutrition's ND to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.

Cancellation Policy:
Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in our ND's schedule that could have been filled by another patient. As such, we require 24 hours notice for any cancellations or changes to your appointment. Patients who provide less than 24 hours notice, or miss their appointment, may be charged a cancellation fee.

Consent to Treatment:
By signing this form, you understand that by working with an ND at Koru Nutrition Inc. you will be fully informed regarding your treatment plan, possible side effects, expected outcomes and possible alternative treatments available. We do not guarantee treatment results, and you have the ability to withdraw your consent to treatment at any time. You also acknowledge that you have the right to ask questions and be involved in your treatment process. Our model is to provide patient-centered health care with informed decision making as a priority.

Consent to Virtual Visits:
By signing this form, I understand that my appointments with the ND will be completed using a secure video platform. I understand that visits conducted virtually do not offer the opportunity for physical exams to be completed. If a physical exam is indicated, I understand that the ND may need to defer my assessment until an in-person appointment can be conducted or may refer me for physical examination elsewhere.

Insurance Submissions and Invoice Policy:
Patients are responsible for maintaining and submitting required receipts to their insurance company for reimbursement of services. Insurance claims that are denied by an insurance company are not the responsibility of the ND or Koru Nutrition Inc.. All invoices are sent to patients electronically to create a permanent file for patients to maintain. Our clinic cannot be responsible for lost or misplaced invoices.