All service recipients must meet the requirements below :
- Submit the Patient form prior to requesting an appointment.
- Patients must have a confirmed appointment.
- Patients under 18 years of age must be accompanied by a guardian.
- Female patients must be in Hijab & be accompanied by a mahram.
- Cancellation permitted 72 hours prior to appointment without penalty.
- Cancellations under 72 Hours prior to appointment will incur a fee of $20.00
- Review and agree to service Terms, Conditions, Consent and Waivers.
- All requests are subject to approval.
- Signed Service Terms, Conditions Signed Waiver
CONSENT FOR RUQYAH TREATMENT
I present to EPIC Ruqyah Center and consent to treatment of the Ruqyah provider on duty and whomever they may designate as their assistant, associate and patient care staff. This treatment may encompass various approaches, including Ruqyah recitation, acupressure, use of spittle, blowing air, tactile contact, recommendations on use of herbs, oils, aroma therapy, massages, cupping and the provision of spiritual advice during the course of care. I am aware that no assurances have been given or can be given regarding the outcomes of treatments or consultations, and I fully comprehend that all interventions carry inherent risks.
PAYMENT GUARANTEE
I acknowledge that I am accountable for and will cover the portion of expenses incurred. I commit to settling the entire amount indicated on my billing statement promptly, unless alternative payment agreements have been established with EPIC Ruqyah Center. It is our established protocol that all outstanding fees must be settled before the commencement of services.
RELEASE OF PATIENT INFORMATION
I authorize the release of my records & information to:
- Medical providers, agents of another healthcare facility if transfer to another facility is required.
- Religious, educational or scientific institutions, on anonymous basis, The patient agrees that in all instances, the original records remain the property of EPIC Ruqyah Center.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO IT. PLEASE REVIEW IT CAREFULLY.
How we handle your information: We may use and disclose your information. We use information about you for treatment, for administrative purposes, and to evaluate the quality of service that you receive. For example, your Information may be shared with other providers to whom you are referred. Information may be shared by paper, mail, electronic mail, fax, or other methods. We may use or disclose your information without your authorization for several reasons. But beyond those situations, we will ask for your written authorization before using or disclosing your Information. If you sign an authorization to disclose Information, you can later revoke it to stop any future uses and disclosures.
CONSENT FOR TREATMENT
I understand that my/my child(ren) condition requires Ruqyah treatment. I consent to and authorize Ruqyah treatment as directed by the Ruqyah practitioner and his/her consultants, associates and assistants. I authorize ERC, employees, volunteers and others as necessary to carry out the instructions of the Ruqyah practitioner with respect to the procedures and treatment they have ordered. I understand that ERC does not provide any medical advice or treatment and it may be necessary for representatives of outside health care companies to assist in my/my child(ren) care. I also understand student and others in professional training programs and volunteers may be among the individuals who provide Ruqyah service to me/my child(ren). I understand that in connection with my/my child(ren) treatment, photos or videos may be taken.
NO GUARANTEE: I acknowledge that no guarantees or warranties have been made with respect to treatment to be provided at this Center to me/my child(ren).
