I, _____________________________________, consent to receive naturopathic care, acupuncture and recommendations from Shana Deneen, ND, Dipl.Ac. I understand that I will not be receiving diagnostic information from my Naturopathic Doctor (ND). Dr. Shana Deneen is licensed as a naturopathic physician in the state of Arizona and she received her four years of post-graduate naturopathic medical education through CMNE approved programs. I understand that the state of Oklahoma does not license NDs and that Dr. Shana Deneen is not a Medical Doctor (MD) nor Osteopathic Doctor (DO). I also understand that I will not be receiving any medical treatment or prescriptions from Dr. Shana Deneen.
I understand that the information I share with Dr. Shana Deneen, will be kept confidential with the following exceptions: (1) Information regarding dangerous or illicit alcohol or drug use; (2) Disclosure of child, elder or other abuse; (3) Disclosure of intent to harm oneself or others. Dr. Deneen will report the above exceptions to the Oklahoma Department of Human Services (DHS); (4) In the event of an emergency where your emergency contact needs to be notified and/or emergency services need to be notified to provide medically necessary care for you in the event that you are unable to execute this on your own. I understand that if Dr. Deneen determines that I am in urgent need of medical evaluation, she will refer me to my primary care physician or the Emergency Room. I understand that I must consult with my licensed medical provider to obtain medical evaluation, medical diagnosis, and medical treatment.
Acupuncture is the insertion of a thin needle into the surface of the body. A patient may feel a slight pricking sensation and/or