INFORMED CONSENT FOR MEDICAL/COMPLEMENTARY AND ALTERNATIVE MEDICINE TREATMENTS
Medical care is a patient care service provided in response to a wide range of medical care needs of patients of all ages regardless of gender, color, race, creed, national origin, or disability, on an as-needed basis.
The purpose of medical care is:
● To treat disease, injury, and disability by examination, testing, and use of procedures in aid of diagnosis and treatment.
● To obtain information needed in diagnosing and examining patients.
● To prevent or minimize physical and mental disability.
● To aid patients in achieving their maximum potential within their capabilities.
● To accelerate convalescence and reduce the length of the functional recovery.
As a patient, I have the right to be informed about my condition and recommended care. This disclosure is to help me become better informed so I may make the decision to give or withhold my consent as to whether or not to undergo care having had the opportunity to discuss potential benefits, risks, and hazards involved.
I hereby request and voluntarily consent to examination and treatment with complementary and alternative medicine, possibly including homeopathic medicines, vitamins, minerals, supplements, IV therapies, injections, detoxification treatment, lab testing, nutrition recommendations, etc. for me (or for the patient named below, for whom I am legally responsible) by Tchefuncte Health and Wellness and Spencer Pinion, MD, Elizabeth McLain, NP, Misty Breakfield, PA or any other licensed medical providers. I can request further explanation of the procedure or treatment, other alternative procedures or methods of treatment, and information about the material risks of the procedure or treatment.
I understand that the U.S. Food and Drug Administration has not fully evaluated or approved nutritional, herbal, and homeopathic supplements, compounded IVs/injections, and bio-identical hormone replacement therapies; however, they have been widely used in Europe and the U.S. for years. I understand that, as with any drugs, hormones, nutritional supplements, and injections may exhibit some side effects in certain sensitive individuals, may interact with certain allopathic medications or labs test, or show symptoms, due to certain pre-existing disease conditions. I do not expect the medical provider to be able to anticipate and explain all risks and complications, and I wish to rely on the medical provider to exercise judgment in recommending the dietary supplements, medications, and treatment, that the medical provider feels at the time, based on the fact then known, is in my best interest. I understand that if I do not take the supplements or treatments as recommended, I may not get the desired results or may increase the chances for an adverse effect.
It is my responsibility to keep my medical provider up to date with all of the current medications and supplements that I am taking so that he/she can make the best-informed recommendations for my care.
I have the opportunity to ask questions and discuss with my provider to my satisfaction:
● My suspected diagnosis or condition
● The nature, purpose, and potential benefit of the proposed care
● The inherent risks, complications, potential hazards, or side effects of the treatment or procedure
● The probability or likelihood, of success
● Reasonably available alternatives to the proposed treatment or procedure
● The possible consequences, if treatment or advice is not followed and/or nothing, is done.
I further acknowledge that no guarantees or assurances have been made to me concerning the results intended for the treatment.
I understand that a complementary and alternative medicine evaluation and treatment may include, but is not limited to collecting specimens for laboratory evaluation, ordering diagnostic imaging, prescription of certain medications and nutritional supplements, IV therapy, bio-identical hormone replacement therapy, injections, counseling, dietary therapies or other alternative remedies.
I understand that the medical providers at Tchefuncte Health and Wellness have been trained in a diverse range of diagnostic and treatment options. I understand that Tchefuncte Health and Wellness is highly specialized and based upon evidence-based medicine, including functional medicine and holistic principles. As such, they may recommend different tests; may interpret standard tests differently; may propose different treatments, or may administer standard treatments differently than most conventional physicians as many perspectives exist in medicine, and in some cases, there may be a disagreement among qualified medical experts. Care rendered may therefore be seen by some as the outside standard of care or medically unnecessary. Diagnosis and treatment may include some services considered non-traditional, non-conventional or alternative medicine.
These services may not be recognized as standard medical practices and may be considered by insurance companies to be experimental or investigational. Along with training, the rationale for these differences is based on clinical experience and ongoing continuing education in evidence-based functional and lifestyle medicine.
By signing this form, I acknowledge I have carefully read, or have had read to me, and understand the above consent. I give my permission and consent to care and authorize medical treatment by Tchefuncte Health and Wellness and their staff, and I am fully aware of what I am signing. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment and I may ask my medical provider for a more detailed explanation.
There are certain inherent risks with medical care. The attending physician/provider will take every precaution to ensure that you are protected from any potentially hazardous situation.
You will never be forced to undergo any medical treatment that you do not wish to undergo.