Waiver for Homeopathic Care by Roger Barr, Professional Homeopath

To: __________________________
(name of client)

Welcome to my practice. As you know, I am a practitioner of Homeopathy. I am not a licensed physician, nor are Homeopaths services licensed by the state. The idea behind Homeopathy is that:

Homeopathy is a practise whereby the natural healing power of the body is stimulated by extremely dilute non-toxic quantities of substances.

As a practitioner of Homeopthy, I will provide you with the followings kinds of services:

I will interview you extensively to determine the appropriate homeopathic remedies for you as needed. I will follow the progress of your healing and advise you on when and how to change your homeopathic treatment.

I have been practicing Homeopathy for since 1992. My training and education is described below:

• Pacific Academy of Homeopathy (Certificate of Classical Homeopathy, 2 years)
• Lou Klien's Homeopathic Master Clinician Course (CMC Certificate, 2 years).
• Paul & Amy Herscu's New England School of Homeopathy Level 2 (one year)
• International Federation of Homeopathy Case Conferences (3 years)
• Robin Murphy's Hahnemannian Academy of North America (2 years)
• Four Winds Seminars, many different homeopaths over many years including: Dr. Rajan Sankaran, Dr. Roger Morrison, Dr. Michael Carlson (on staff at Sonoma State Medical School), Nancy Herrick, Judith Reichenburg-Ullman
• Giri Wescott's workshop series

In order to use my services, California state law requires that you acknowledge receipt of the information provided in this form and that you sign it. You will receive a copy. I will keep the original in my records for at least three years.

My method of treatment, Homeopathy, is alternative or complementary to healing arts that are licensed by the State of California. Under Sections 2053.5 and 2053.6 of California’s Business and Professions Code, I can offer you these services, subject to requirements and restrictions that are described fully below.

If you ever have any concerns about the nature of your treatment, please feel free to discuss them with me. I recommend that you inform your medical doctor that you are receiving Homeopathy treatment.

CALIFORNIA SENATE BILL SB-577

WHAT IT MEANS FOR PATIENTS

California Senate Bill SB-577, which was signed by the governor in September 2002, has profound implications for the practice of alternative forms of health care in California. SB-577 enables alternative and complementary health care practitioners to provide and advertise their services legally. However, they must also comply with certain requirements specified within the bill.

What does Senate Bill SB-577 mean for you, the patient?

SB-577 gives you access to alternative and complementary health care practitioners. You must be given information about the nature of treatment and the practitioner’s qualifications. Feel free to ask a practitioner any question you might have about your treatment. Check to see if your practitioner has been certified by a professional membership society. In addition, tell your doctor about any alternative treatment you are pursuing. You can also request that your licensed and unlicensed health care providers communicate with each other and work collaboratively to meet your health care needs.

SB-577 helps to protect you. SB-577 requires unlicensed alternative health care practitioners to follow certain guidelines and restrictions.

Here are the things that unlicensed alternative practitioners are NOT allowed to do:

•  Perform any form of surgery or any procedure that punctures your skin or harmfully invades your body.
•  Use X-ray radiation.
•  Prescribe prescription drugs, or recommending that you discontinue drugs that were prescribed by a licensed physician.
•  Set fractures.
•  Treat wounds with electrotherapy.
•  Put you at risk of great bodily harm, serious physical or mental illness, or death.
•  Imply in any way that they are licensed physicians.

In addition, an unlicensed alternative practitioner MUST DO the following things:

• Provide you with a statement, written in plain language that includes the following information: (1) that they are not a licensed physician and that their services are not licensed by the state; (2) a brief and clear description of the kind of services they provide and the reasoning behind it; and (3) a description of their education, training, and experience.
• Ask you to sign an acknowledgement that you received the above written statement, and provide you with a copy of it. They must also keep a copy of your signed acknowledgement for three years.

Acknowledgement and Consent to Receive Services:

I have read and understand the above disclosure about the Homeopathy treatment offered by Roger Barr and Roger Barr’s training and education. I have discussed with Roger Barr the nature of the services to be provided. I understand that Roger Barr is not a licensed physician and that Homeopaths services are not licensed by the state. I understand it is my responsibility to maintain a relationship for myself/my child with a medical doctor. I have consented to use the services offered by Roger Barr, and agree to be personally responsible for the fees of Roger Barr in connection with the services provided to me.

Signed: ___________________________ Date: _________________________
(client/parent/conservator/guardian)

Indicate capacity to sign if other than client ________________________
(Parent to sign for child)

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