INFORMED CONSENT FOR TREATMENT
I hereby request and consent to the performance of the following specific procedures on me (or on the patient named above for whom I am legally responsible) by the practitioners of Collaborative Natural Health Partners,
Primary Care, Osteopathic medicine and functional medicine: providing the standard of care for primary medicine while offering natural alternatives when possible. Gynecology. Common diagnostic procedures: e.g., physical exams, venipuncture, Pap Smears, laboratory Minor office procedures: e.g., dressing a wound, ear irrigation, suture removal, cryosurgery. Medicinal use of nutrition: therapeutic nutrition, nutritional supplementation, nutritional consults. Nutrigenomics: review of genetic information for nutritional purposes. The undersigned acknowledges that Collaborative Natural Health Partners, LLC does not employ any geneticists, and none of the employees of Collaborative Natural Health Partners, LLC should be considered substitutions for geneticists. Botanical Medicine: botanical substances may be prescribed as teas, alcoholic tinctures, capsules, tablets, creams, plasters or suppositories. Homeopathic remedies: the use of highly dilute quantities of naturally occurring plants, animals and minerals to gently stimulate the body's healing responses. Lifestyle Counseling and Hygiene: healthy lifestyle classes, diet therapy, promotion of wellness including recommendations for exercise, sleep, stress reduction and balancing of work and social activities. Psychological Counseling. Physical Medicine: osseous manipulation, soft tissue manipulation, electrotherapies, hydrotherapies, paraffin bath, intersegmental traction, cupping, acupuncture. Acupuncture Nutritional Consultations Healthy Lifestyle Classes Other Procedures: I understand that results are not guaranteed, and I recognize the potential risks and benefits of these procedures as described below:
General Potential risks: allergic reactions to prescribed herbs and supplements, side effects of natural medications, inconvenience of lifestyle changes, injury from venipuncture or procedures, fainting, aggravation of pre-existing symptoms, discomfort, pain, bruising, burns, lightheadedness. Potential Risks of Acupunture: bruising, numbness or tingling near the needling sites, dizziness or fainting, unusual risks include nerve damage, organ punctures, spontaneous miscarriage and infection. Potential Risks of Cupping: bruising and scarring.
Potential Risks of Taking Herbs: nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives and tingling of the tongue.
I understand that Collaborative Natural Health Partners, LLC cannot anticipate and explain all risks and complications and I choose to rely on the practitioners of Collaborative Natural Health Partners, LLC to exercise their judgment during the course of the procedures which they believe at the time, based upon the facts they know, is in my best interests. Potential benefits: restoration of health and the body's functional capacity, relief of pain and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or its progression.