By booking a Program Consultation with a Licensed Physician (“Care Team”), I indicate my consent which authorises Alavida Health Ltd. (“Alavida”) to collect the information needed for the Care Team to deliver the information session and provide best answers to my questions as possible.

I understand that Alavida uses SMS to communicate with clients. I consent to Alavida sending me SMS messages. If I wish to unsubscribe I may do so at any time by texting “ STOP ” to 242643 , using the settings in the Alavida App or by contacting Client Services directly.

We will never share your personal information with anyone without your prior consent. If you would like to review the Alavida PRIVACY POLICY in full, it can be found on our website at the following address: www.alavida.co/privacy.

PERSONAL INFORMATION

By accepting this form, I agree that I have given my informed consent to the collection, use, and/or disclosure of my personal information as outlined in the Alavida PRIVACY POLICY. I have reviewed the Alavida PRIVACY POLICY and understand how Alavida will use my personal information and the steps that Alavida is taking to protect my information. I agree that Alavida can collect, use, and disclose personal information as set out in the Alavida PRIVACY POLICY.

CONTENTS

I understand that the Program Consultation cost is $100.00 plus applicable taxes, and that if I choose to join the program, 100% will be returned to me as a reduction of the total cost of the program.

The Program Consultation will consist of a 30 minute appointment with the Care Team wherein my personal medical information, Alavida’s treatment programs and/or other care alternatives will be discussed. I will have the opportunity to ask questions that relate to my suitability for treatment with the Care Team. Due to the time-limited nature of the Program Consultation, I understand that I will not have the ability to discuss non-related medical issues. Further, I also understand that Alavida’s Care Team will not be acting as my primary care physician.

CANCELLATION OF APPOINTMENT

In the case that an appointment cannot be kept, Alavida requires 24 hours’ (excluding weekends and holidays) notice to cancel or reschedule appointments. In the event that I am unable to provide sufficient notice I understand that my appointment will be considered “missed” and I will be charged in full.

LIMITS OF CONFIDENTIALITY

Information discussed with Alavida’s Care Team is confidential, and is not shared without the client’s written permission except under the following circumstances:

  • If the client is judged to be at serious risk of doing significant harm to himself or herself, or to someone else.
  • If the client reports information indicating that a vulnerable person is in need of protection (e.g. a child or elderly person being abused).
  • If the client holds a driver’s license and is not safe to be operating a motor vehicle.
  • If records are subpoenaed by a court of law.

In addition to these limits, information discussed with Alavida’s Care Team may be shared among other Alavida care team members for the purposes of providing personalized follow-up after the session, as outlined in the Alavida PRIVACY POLICY.