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This is a confidential record of your medical history and will be kept in this office. Information contained in it will not be released to any person unless authorized by you. I understand that I should be evaluated by a physician for the condition I am requesting. The diagnosis and treatment plan I will be given by Starry Brook Natural Medicine is based upon Traditional Chinese medical principles and/or Naturopathic Philosophies and may not constitute a western medical diagnosis. I understand if no substantial improvement is made in the condition for which I am seeking consultation, I am to seek advice form a western medical doctor. Further, it is my responsibility to advise my physicians of any supplements, medications or treatments I am concurrently receiving. Starry Brook requires 48 hour cancellation notice. If I do not provide notice for cancellations, I understand I may be charged for the missed appointment.