Consultation with Dr. Kondrot

Application for Consultation with Dr. Kondrot

First Name *

Middle Initial

Last Name *

Date of Birth *

Gender *

Weight in Pounds *

Street Address *

City *

State *

Postal Code *

Best Phone Number to call *

Email Address *

Yes! Please sign me up for your e-newsletter which contains monthly information to help maintain and improve my vision.

How did you hear about Healing the Eye and Wellness Center (Dr. Edward Kondrot)? *

If a referral, whom may we thank?

EMERGENCY CONTACT INFORMATION

Name of Contact *

Phone # *

May we leave a message on your home phone number regarding your care at Healing the Eye and Wellness Center? *

If yes, please initial.

Please list any others: spouse or family member to whom we may release your private information.

Name

Phone

Relationship

Name

Phone

Relationship

Name

Phone

Relationship

Primary reason / complaint for seeing the doctor. *

Use Pacemaker Defibrillator?

YesNo

If you currently use a pacemaker and or defibrillator, you will need to have your physician fill out our pacemaker and or defibrillator release document. We will supply this to you after you complete your registration.

Allergies

List Medical Problems

List Medications

Doctor/Patient Contract

I understand that in seeking medical treatment from Edward C. Kondrot, MD(h), CCH, DHt, FCOS, who will hereinafter be referred to as the "Doctor", whether speaking of one or more of them, I am not required to use him as my doctor for myself or my family as there are other doctors as well qualified who practice medicine in the specialty of ophthalmology, optometry, naturopathy, acupuncture and homeopathy that he/she is willing to refer me to them.

I understand that if I waive any liability for his care of me and my family, I will help the Doctor keep down the expenses of his practice of medicine due to savings in avoiding malpractice insurance and malpractice lawsuits, the expenses of which would otherwise be passed on to me and his other patients in higher fees. I enter into this contract voluntarily and I understand I am waiving my right to bring a claim against the Doctor for any negligent act or omission he may commit in his treatment of me or for any breech of the contractual obligation to me to render to me that standard of medical care which is rendered in this contract applies to all of his medical care to me.

I specifically release the Doctor from any liability to me and I hereby release, discharge and acquit the Doctor from any and all claims for loss, damage or injury of any nature whatsoever to my person, my family or estate, resulting in any way, form or in any fashion arising from, connected with or resulting from the Doctor's medical treatment of me or my family whether caused by malpractice or negligent acts of the Doctor, his agents, or employees or servants or otherwise. This contract is clearly intended to protect the Doctor against his own negligence and I so understand it.

I voluntarily enter into this contract in order to induce the Doctor to render to me medical as well as alternative therapies at his most reasonable cost. Additionally, if the aforementioned release and/or waiver is determined by any court to be void and not binding upon me, I am willing to submit any claim for loss, damage or injury of any nature whatsoever to my person or estate resulting in any way form or in any fashion arising from connected with or resulting from the Doctor's treatment of me whether caused by malpractice, breach of contract or negligent acts of the Doctor, his agents, employees, servants or otherwise, to binding arbitration.

In such arbitration I agree that there shall be three arbitrators, two of them shall be medical doctors with qualifications similar to Dr. Kondrot in Homeopathy, Ophthalmology or Optometry. Each party shall choose one arbitrator and the two arbitrators shall choose the third. The decision of the arbitrators shall be final and binding upon me with respect to the decision of liability and amount.

TREATMENT CONSENT

I AUTHORIZE THE PERFORMANCE UPON (MYSELF, NAME OF PATIENT) AN ALTERNATIVE MEDICINE EVALUATION WHICH INCLUDES BUT ARE NOT LIMITED TO, HOMEOPATHIC, MICROCURRENT, NUTRITIONAL, COLOR, VISION AND IV THERAPIES. I MAY OR MAY NOT BE A CANDIDATE FOR THE THERAPIES LISTED AND I AM SEEKING ADVICE FROM DR. EDWARD C. KONDROT.

THESE HAVE NOT BEEN PROVEN THROUGH SCIENTIFIC RESEARCH. WHILE TRYING THE SUGGESTED APPROACH, I WILL REMAIN UNDER THE CARE OF MY MEDICAL DOCTOR AND WILL HAVE MY HEALTH/VISION CHECKED PERIODICALLY. HE OR SHE MAY RECOMMEND OTHER TREATMENT, SOME MAY NOT BE AVAILABLE AT THE TIME OF CONSENT. IF THIS IS THE CASE I WILL EVALUATE MY OPTIONS.

THE FOLLOWING TREATMENTS ARE OPTIONAL AND HAS SPECIFICALLY BEEN DISCUSSED AS INDICATED BY MY INITIALS:

IV TREATMENT;
INCLUDING BUT NOT LIMITED TO; MYERS NUTRITIONAL COCKTAIL, OZONE, CHELATION, PK PROTOCOL:

I UNDERSTAND THE NATURE AND RISK OF ALTERNATIVE THERAPIES AND THE POSSIBLE COMPLICATIONS. I WILL BE USING ALTERNATIVE THERAPIES AS A COMPLIMENT TO MY REGULAR MEDICAL PROGRAM AND I WILL NOT DISCONTINUE ANY MEDICATION OR TREATMENT WITHOUT THE PRIOR APPROVAL OF MY EXISTING DOCTOR. I ALSO UNDERSTAND THAT THERE IS NO GUARANTEE OR ASSURANCE HAS BEEN GIVEN BY ANYONE AS TO THE RESULT THAT MAY BE OBTAINED. I HAVE BEEN EXPLAINED AND I UNDERSTAND THE ABOVE AND I REQUEST TO HAVE THE PROCEDURE(S) DONE.

Initials *

WITNESS

Name *

Patient Signature

Electronic Signature *

I understand that by filling out my signature (above) and clicking the "Submit" button (below) I agree to the Financial Agreement, Doctor/Patient Contract, and Treatment Consent.
You will be directed to a page to make your $500.00 non-refundable consultation fee. This also includes a one month follow up. If you are a candidate for Dr. Kondrot's Healing the Eye Program this fee will then be applied towards the program.