Informed Consent Form

I certify that I have been informed in a manner that is clear and transparent to me about the nature, purpose, importance and course of the consultation, examination(s), treatment(s) and/or follow-up, as well as the expected result and any risks and inconveniences.

Moreover, I was informed by Dr. Werner Faché about the financial implications and its cost in a clear and transparent manner before he started providing care as a general practitioner with a preventive lifestyle approach:

• I understand and acknowledge that Dr. Werner Faché is not contracted, and that his fee or honorarium for a consultation in the context of examination(s), treatment(s) and/or follow-up, depending on the service(s) provided and the time frame, is between €250 and €350, and I agree to this supplementary cost(s).
• I understand and acknowledge that health insurance will intervene for a routine blood test, as clearly discussed prior, and I agree to the co-payment and any supplement.
• I understand and acknowledge that health insurance does not intervene for the prescription, purchase and use of specific medically validated collection kits and the analysis of their blood, urine and/or fecal samples by accredited laboratories, as clearly discussed beforehand, and I agree to these additional cost(s).
• I understand and acknowledge that health insurance does not intervene for the prescription, purchase and use of dietary supplements, as clearly discussed prior, and I agree to these supplemental cost(s).

I have had the opportunity to ask Dr. Werner Faché additional questions and this doctor has answered me adequately. I have received and had access to the brochure (Appendix 1) with additional information. I understand that it is my responsibility to know what cost(s) my own insurance will or will not cover.

If you wish to purchase certain dietary supplements through specialized web shops, you may use a general discount code that is currently publicly available on the provider’s own website. Please note that I am not affiliated with this webshop, do not receive any compensation or benefit, and provide this information purely to support patient accessibility. You are, of course, free to choose your preferred provider or pharmacy.

Patient name: ……………………………………………………………………………

Date: ……………………………………………………………………………………

Patient signature preceded by “read and approved”:
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