I hereby authorize Dr. Jessica Folz to perform the following specific procedures as necessary to facilitate my diagnosis and therapeutic healing:
- Common diagnostic procedures: e.g. venipuncture, physical examination, radiography, laboratory test, x-rays and other imaging.
Minor office/in-home procedures: e.g. bioidentical hormone pellet therapy, JOOVV red light therapy, ozone therapy, PRP, trigger point injections
- Medicinal nutrition: e.g. therapeutic nutrition, nutritional supplementation, intramuscular vitamin injections, and IV therapy.
- Botanical medicine: e.g. botanical substances may be prescribed as teas, alcoholic tinctures, capsules, tablets, creams, plasters or suppositories.
- Homeopathic medicine: e.g. the use of highly dilute quantities of naturally occurring plants, animals and minerals that gently stimulate the body’s healing responses
- Lifestyle counseling and hygiene: e.g. diet therapy, promotion of wellness including recommendations for exercise, sleep, stress reduction, and balancing of work and social activities
- Physical medicine: e.g. massage, hot and cold therapy, stretching, hydrotherapy, and injection therapy, including peptides. recognize the potential risk and benefits of these procedures described below:
I recognize the potential risk and benefits of these procedures described below:
- Potential risk: Allergic reactions or side effects to prescribed herbs, pharmaceuticals, supplements, natural medications or vaccinations.
- Aggravation of pre-existing symptoms, discomfort, pain, infections, burns, nausea, lightheadedness, inconvenience of lifestyle changes, injury from injections, venipuncture or procedures. Notify Dr. Jessica Folz immediately if you experience any symptom which may be secondary to the above procedures.
- Potential benefits: Restoration of health and the body’s optimal functional capacity without the use of more aggressive interventions such as drugs or surgery.
- Relief of pain, and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or its progression.
- Notice to all women: All female patients must alert Dr. Jessica Folz if they know or suspect that they are pregnant, or are currently nursing, as some therapies may present a risk to pregnancy and possibly to nursing safety.
With this knowledge I voluntarily consent to the above procedures realizing that no guarantees have been given to me by Dr. Jessica Folz, or any of the associated personnel regarding cure or improvement of my condition(s).
I understand that I am free to withdraw my consent and to discontinue participation in any of these procedures at any time. If I choose to deny consent, especially in the face of sound medical advice, I am aware that it shall be documented thoroughly, and repercussions for denial of consent shall not fall upon Dr. Jessica Folz.
I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others, unless directed to do so by myself or my representative, or unless law requires it.
I understand that I may look at my medical record at any time and can request a copy of it by paying the appropriate printing, processing and mailing fee.
I understand that my medical record will be kept for a minimum of three but no more than ten years after the date of my last visit.
I understand that information from my medical record may be analyzed for research purposes, and that my identity will be protected and kept confidential. I understand that any questions I have will be answered by my practitioner to the best of their ability.