Patient Agreement

Between:

Can Ikram, Clinic153
Website: www.clinic153.com
Address: at the Osteopathy & Natural Medicine Schwabing, Hohenzollernstrasse 97 80796 Munich, Germany
Email: info@clinic153.com

And:

Patient Name: [Insert Patient Name]
Address: [Insert Patient Address]
Date of Birth: [Insert Date of Birth]
Contact Information: [Insert Contact Information]

1. Purpose of the Agreement

This agreement outlines the terms and conditions for the treatment provided by Can Ikram at Clinic153, a private practice specializing in homeopathy. The agreement ensures mutual understanding regarding the services offered, data privacy, fees, and the responsibilities of both the patient and the practitioner.

2. Treatment and Services

The patient agrees to undergo medical treatment provided by Can Ikram at Clinic153. Treatment will be based on an initial anamnesis (health assessment), diagnosis, and individually tailored therapy plan. The treatment may include consultations, diagnostics, and prescribed therapies, which will be discussed and agreed upon in advance.

2.1. Anamnesis and Documentation
The patient agrees to provide complete and accurate medical history and health-related information necessary for the treatment. The patient acknowledges that failure to provide sufficient information may limit the effectiveness of the treatment.

2.2. Informed Consent for Alternative Therapies
The patient acknowledges that homeopathy is an alternative form of treatment and may not be recognized by mainstream medical institutions. The patient consents to receiving homeopathic care with an understanding of its potential benefits and limitations.

2.3. Non-Emergency Treatment Acknowledgment
The patient acknowledges that homeopathy is not intended for emergency medical situations. In the event of a medical emergency, the patient agrees to seek immediate medical attention from conventional healthcare providers (e.g., hospitals, emergency services).

2.4. No Guaranteed Results
The patient acknowledges that homeopathic treatments are highly individualized and that no specific results or guarantees can be made regarding the effectiveness of the treatment.

2.5. Dietary and Lifestyle Recommendations
The patient agrees to follow any dietary, lifestyle, or other recommendations provided as part of the homeopathic treatment plan, understanding that these are important aspects of the healing process.

2.6. Follow-up and Ongoing Treatment
The patient acknowledges that homeopathic treatment is often an ongoing process, and follow-up appointments may be necessary to adjust the treatment plan. The patient agrees to attend these follow-ups as part of their care.

2.7. Non-disclosure of the Homeopathic Remedy
The patient agrees that the name of the homeopathic remedy will not be provided to them during the course of treatment. If treatment is discontinued and a new practitioner takes over, the name of the last homeopathic remedy administered will be provided to the new practitioner upon their request.

2.8. Video and Text Recordings
For case documentation purposes, the patient consents to the video recording and written documentation of consultations, which will be securely stored in accordance with the clinic’s privacy policy. The patient may request access to these records at any time.

3. Data Privacy and Protection

The patient acknowledges that their personal and health data will be collected, processed, and stored in accordance with the General Data Protection Regulation (GDPR) and the Telecommunications and Telemedia Data Protection Act (TTDSG).

3.1. Collection and Processing of Data
The patient’s data, including name, contact information, medical history, diagnosis, and treatment records, will be collected for the purpose of providing medical care. This data will be treated confidentially and shared with third parties only when legally required or with the patient’s explicit consent.

3.2. Privacy and Data Handling (Specific to Homeopathic Case Studies)
The patient consents to their treatment data being used in anonymized form for educational or research purposes, with the understanding that their identity will remain confidential. The patient has the right to withdraw this consent at any time.

3.3. Data Retention
Patient records will be stored for a minimum of 10 years following the completion of treatment, in accordance with legal obligations. Other retention periods may apply as per statutory regulations.

3.4. Consent to Third-Party Services
The patient consents to the processing of their billing information through a third-party medical billing service, which will handle invoicing and, if necessary, collections on behalf of Can Ikram or Clinic153. Only the minimum data necessary for these purposes will be shared.

4. Patient Rights

The patient has the following rights concerning their data:

Access: The right to request information on stored personal and medical data.
Correction: The right to correct any inaccuracies in the stored data.
Deletion: The right to request the deletion of data, provided it does not conflict with legal obligations.
Data Portability: The right to transfer their data to another provider if desired.
Withdrawal of Consent: The patient may withdraw their consent for the processing of personal data at any time.

To exercise these rights, the patient may contact Can Ikram at info@clinic153.com.

5. Appointment Scheduling and Cancellation

5.1. Appointment Booking and Acceptance of Terms
By scheduling an appointment over the website, email, phone, WhatsApp, or any other communication method, the patient acknowledges and agrees to these terms and conditions. No further signature is required to formalize the agreement, though one may be requested at any time by either the practitioner or the patient.

5.2. Cancellation Policy
The patient agrees to notify the clinic at least 24 hours in advance if they need to cancel or reschedule an appointment. Failure to do so may result in a cancellation fee.

6. Fees and Payment

6.1. Fee Structure
Clinic153 is a private practice and does not charge according to the Gebührenverzeichnis für Heilpraktiker (GebüH). Instead, the fees are determined by a range or a subscription model as outlined on the clinic’s website at www.clinic153.com. The individual service price range will be a multiple of 1.5, 2.3, 2.5, or 3.5, determined with reference to the billing directory for homeopathic services of the Association of Classical Homeopaths Germany e.V. (LVKH). The patient agrees to this fee structure and understands that it is their sole responsibility to clarify coverage with their insurance company if applicable.

6.2. Payment Terms
For individual treatments, fees are to be paid promptly within 7 days of receiving the invoice. For patients on a subscription model, subscription fees will be automatically deducted from the electronic payment method chosen by the patient on the website.

6.3. Patient Responsibility
It is the sole responsibility of the patient to verify and clarify coverage with any insurance company. Clinic153 will not communicate directly with insurance providers regarding coverage or reimbursement.

7. Exclusion of Conventional Medications

The patient acknowledges that any decision to reduce or stop conventional medication must be made in consultation with their primary healthcare provider. The homeopathic treatment provided does not replace or negate the need for conventional medical care when necessary.

8. Liability

Can Ikram will provide services in accordance with professional standards and the best available medical knowledge. However, the patient understands that medical outcomes cannot be guaranteed. Can Ikram or the clinic will not be liable for any outcomes beyond what is reasonably expected from the treatment.

9. Arbitration

In the event of any legal disputes arising from this agreement or the treatment provided at Clinic153, both parties agree to seek arbitration before pursuing any legal action. The arbitration will be conducted in accordance with the rules of a recognized arbitration body, and both parties agree to abide by the outcome of the arbitration.

9.1. Arbitration Procedure
The patient and Can Ikram agree to initiate arbitration by notifying the other party in writing of the dispute. Arbitration will take place at an agreed-upon location, and each party will bear its own legal and arbitration costs unless otherwise agreed in the final arbitration decision.

9.2. Legal Action After Arbitration
Only after the arbitration process has been fully completed, and if either party is not satisfied with the result, may legal action be pursued in the courts. The jurisdiction for any such legal action shall be the courts in Munich, Germany.

10. Termination of the Agreement

This agreement may be terminated by either party at any time. Upon termination, Clinic153 is required to retain medical records as mandated by law, but no further treatment will be provided.

11. Governing Law and Jurisdiction

This agreement shall be governed by the laws of Germany. Any disputes arising from this agreement will be subject to the exclusive jurisdiction of the courts in Munich, Germany, except as provided under the arbitration clause.

12. Final Provisions

By scheduling an appointment, the patient confirms that they have read and understood this agreement, including the privacy policy and fee structure, and agree to its terms. No additional signature is required unless requested by either party.

Place, Date: [Insert Place and Date]
Patient Signature: [Patient Name] (if requested)
Practitioner Signature: [Can Ikram] (if requested)