Informed Consent 1 of 2 – Your Labwork
This form is designed to present benefits and risks of the therapies offered at Integrative Health (IH) and must be signed before treatment is rendered. Ask your doctor if you have any questions or concerns regarding your consent to treat prior to signing this Informed Consent form. Treatments, procedures and/or products used in your treatment at Integrative Health may or may not be FDA approved.
Treatments may include one or a combination of the following:
- Dietary and nutritional counseling
- Nutritional and other supplementations, either orally, topically or as injection/IV therapy such as: vitamins, minerals, enzymes, amino acids, essential fatty acids, homeopathic remedies, homotoxicological preparations and others
- Physical medicine (manipulation), acupuncture, trigger point injection, nutritional or other IV therapy, chelation (‘detox’) therapy, hormone replacement therapy and more.
I am seeking medical health care services, including alternative medical therapies at IH. I hereby request and consent to the performance of physical medicine (including but not limited to various modes of physical therapy and diagnostic testing/examination) or to the performance of acupuncture (including but not limited to needle puncture, point injection, and infrared therapy) or to the performance of naturopathic procedures (including but not limited to examination, diagnostic testing and the use of natural substances such as vitamins, minerals, botanical medicines and prescription drugs) on me (or on the patient named, for whom I am legally responsible) by the doctors and staff of naturopathic medicine at Integrative Health.
I understand and am informed that results from treatments may vary and are not guaranteed. In addition, I understand that my compliance with diet recommendations, supplements, prescribed medications, prescribed exercises and lifestyle modification will increase the effectiveness of my care and enhance or maintain the results.
I understand a referral to another physician or specialist may be necessary due to the nature of my condition and limitations in the scope of practice of Naturopathic Medicine.
I acknowledge that the scope of practice of a Naturopathic Physician has limitations including limited prescription privileges and lack of hospital privileges. Consequently a referral to a specialist or emergency room may be deemed necessary under certain circumstances and is in my best interest. Referrals may not be covered by your insurance carrier.
I understand that this medical practice uses diagnostic and treatment methods that are known as investigational, complementary, alternative, holistic, nutritional, and herbal oriented. Some of these methods have not been accepted by consensus mainstream medicine or the FDA.
I understand that I am in no way obligated to purchase the products or run labs recommended by physicians or staff at IH.
I am free to purchase these products from any source that I may choose.
I do not expect the doctor to be able to anticipate and explain all the risks and complications that could possibly happen during or because of treatment and I wish to rely on the doctor to be able to exercise judgment during the course of the procedure based upon the facts known at that time.