Statement of Consent

  1. consent to diagnose and treatEmergency: If this is an emergency, I will dial 9-1-1 on my telephone. Affordable Family Clinic does not provide emergency medical care.
  2. Payment: Payment must be made in full prior to the doctor visit.  Payment is for one medical concern during a 5 minute consultation by a licensed physician.  Multiple concerns require multiple doctor visits.  Payment arrangements are not available.   Payment for a consultation may not result in the requested prescription, and the doctor has the right to not prescribe requested medications if the medication is not indicated.  Furthermore, there are conditions the doctor does not treat, and there are drugs the doctor does not prescribe.  Click here for more details.
  3. Interpretation of Results: Results for labs and imaging require a follow up visit for interpretation.  Each doctor visit is limited to one medical concern, therefore, the follow up visit for interpretation of results is limited to that task.  I will make an additional appointment if I have additional medical concerns.
  4. Fees for Ancillary Services: As a patient of Affordable Family Clinic, I understand that doctor dispenses no medicine, and all prescriptions, including herbs, vitamins and nutrients, are an additional cost to the doctor visit. I understand that I am financially responsible for all fees associated with the cost of care for ancillary services such as prescriptions, labs and imaging. These fees are to be paid directly to the provider (e.g. Fry’s Pharmacy, Bashas’ Pharmacy, Theranos, AZ Tech Radiology, etc.)
  5. Emails: Because emails are not confidential, Affordable Family Clinic cannot discuss my medical information, nor give me a consultation by email.  I will not email Affordable Family Clinic any information regarding my health nor my medical concerns.  I will not email Affordable Family Clinic any financial information such as my credit card number or bank information.  I understand that Affordable Family Clinic will never ask me for health information nor financial information via email.  If I am ever asked for this type of information via email, I will disregard the email and notify Affordable Family Clinic immediately.  Many general questions are answered on the Affordable Family Clinic website at  Specific questions or comments for the doctor can be addressed by calling Affordable Family Clinic at +1 (480) 357-6275.
  6. No Mutual Exclusivity: Any treatment or advice provided to me as a patient of Affordable Family Clinic is not mutually exclusive from any other treatment or advice that I may be receiving now or in the future, from another healthcare provider.   I am at liberty to seek or continue medical care from a physician, surgeon, or other healthcare provider.
  7. Treatment Variance: Allopathic, Naturopathic, Homeopathic, or Chinese medical therapies provided by Affordable Family Clinic may be different from those usually offered by another licensed healthcare provider.  Not all therapies are FDA approved.
  8. Aggravation of Symptoms: Allopathic, Naturopathic, Homeopathic, or Chinese medical treatments can lead to a temporary aggravation of symptoms. Should I experience any symptoms which I associate with natural medicines prescribed, I understand that I should promptly call Affordable Family Clinic at +1 (480) 357-6275.
  9. Side Effects: Any procedure (such as Acupuncture, Intravenous Nutrient Therapy, and Manipulation) or medication intended to help may have side effects.  While the chances of experiencing complications are small, it is the practice of Affordable Family Clinic to inform patients about them.   These complications may include, but are not limited to, soreness, temporary pain or discomfort, inflammation, soft tissue injury or bruising, dizziness, and temporary worsening of symptoms. More serious complications are extremely rare.  Additional information on side effects and complications is available upon request.  It is also clinic policy to inform me of the procedure being performed and the risks and alternative treatments available.  If my physician does not explain to my satisfaction, I will ask for more information.
  10. HIPPA Notice Of Privacy Practices: I have read and understood the HIPPA NOTICE OF PRIVACY PRACTICES and have access to this information.  I have had the opportunity to ask questions.
  11. Consent to Diagnosis and Treatment:  By making the statement, “I consent to diagnosis and treatment by the doctor” means I have read and understand the above and have had an opportunity to ask questions.  I hereby consent to treatment.

If you want more information, visit our FAQs page. or call +1 (480) 357-6275 and talk to a live operator.  Use our Quick Start Guide to get an affordable doctor visit right now.