4531 SE Belmont Ave Ste 313, 97215

Informed Consent for Naturopathic Medical Care, Classical Chinese Medicine & Acupuncture.

I hereby request and consent to examination and treatment with Naturopathic Medicine, Classical Chinese Medicine (CCM) and/or Acupuncture with Dr. Kate Sydney, and/or other licensed doctors of naturopathic medicine or licensed acupuncturists serving as backup for her, hereafter called allied health care provider. I understand that I have the right to ask questions and discuss to my satisfaction with Dr. Kate Sydney, and/ or with the allied health care provider providing backup: (1) my suspected diagnosis(es) or condition(s

(2) the nature, purpose, goals and potential benefits of the proposed care.

(3) the inherent risks, complications, potential hazards or side effects of treatment or procedure.

(4) the probability or likelihood of success.

(5) reasonable available alternatives to the proposed treatment procedure.

(6) potential consequences if treatment or advice is not followed and/ or nothing is done.

I understand that a Naturopathic evaluation and treatment may include, but are not limited to: Physical exam (including general, musculoskeletal, EENT, heart and lung, orthopedic, well- woman/gynecological, prostate, and neurological exams Common diagnostic procedures (including venipuncture, pap smears, diagnostic imaging, laboratory evaluation of blood, urine, stool and saliva Soft tissue and osseous manipulation (including, but not limited to therapeutic massage, strain- counterstrain, naturopathic/osseous manipulation of the spine and extremities Dietary advice and therapeutic nutrition (including use of foods, diet plans, nutritional supplements and intra-muscular vitamin injections Botanical/ herbal medicines, prescribing of various therapeutic substances including plant, mineral, and animal materials. Substances may be given in the forms of teas, pills, creams, powders, tinctures which may contain alcohol, suppositories, tropical creams, pastes, plasters, washes or other forms. Homeopathic remedies (highly diluted quantities of naturally occurring substances Hydrotherapy (use of hot and cold water, may include transcutaneous electrode stimulation Counseling (including, but not limited to diet, tobacco cessation, & weight management counselling Over the counter and prescription medications (including only those medications on the Formulary of Oregon Naturopathic Physicians

I understand that a CCM & Acupuncture treatment may include, but are not limited to: *cupuncture/direct moxa: performed by the insertion of needles through the skin or by the application of heat to the skin (or both) at certain points on or near the surface of the body in an attempt to treat bodily dysfunction or symptoms, to modify or prevent pain perception, and to normalize the body's physiological functions. I am aware that certain adverse side effects may result. These could include, but are not limited to: local bruising, minor bleeding, fainting, burning, scarring, pain or discomfort, pneumothorax, and the possible aggravation of symptoms existing prior to acupuncture treatmentI understand that I am free to stop acupuncture treatment at any time. Chinese Herbs: I understand that I am not required to take these substances but must follow the directions for administration and dosage if I do decide to take them. I am aware that certain adverse side effect may result from taking these substances. These could include, but are not limited to: changes in bowel movement, rashes, abdominal pain or discomfort, and the possible aggravation of symptoms existing prior to herbal treatment.

4531 SE Belmont Ave Ste 313, 97215

Kate Sydney, ND, LAc drkate.sydney@gmail.com

+Cupping / Acupressure / Massage: I understand that I may also be given cupping / acupressure/ tui-na massage as part of my treatment to modify or prevent pain perception, musculoskeletal complaints, and/or to normalize the body's physiological functions. I am aware that certain adverse side effects may result from this treatment. These could include, but are not limited to: bruising, sore muscles or aches, and the possible aggravation of symptoms existing prior to treatment. I understand that cupping. which uses suction over the skin, commonly causes bruise-like marks that can be on the skin for up to one month. I understand that I may stop the treatment if it is too uncomfortable. Electro-Acupuncture: I understand that I may be asked to have electro-acupuncture administered with the acupuncture. I am aware that certain adverse side effects may result. These may include, but are not limited to: electrical shock, pain or discomfort, and the possible aggravation of symptoms existing prior to treatment. I understand that I may refuse this treatment.

Notice to pregnant women: All female patients must alert the provider if they have confirmed or suspect pregnancy as some of the therapies prescribed could present a risk to the pregnancy. Please INITIAL the following:

Notice to individuals with bleeding disorders, pace makers, and/ or cancer. For your safety it is vital to alert your provider, Dr. Kate Sydney, of these conditions.

After reading the items below, please initial that you agree to the statements:

_______I understand that Dr. Kate Sydney is licensed to prescribe controlled substances, but does NOT prescribe them for chronic pain management, as they are not appropriate for long-term use.

_______I understand that Dr. Kate Sydney, will only prescribe medications if she believes that they are in the best interest of myself, the patient.

_______I understand the US Food and Drug Administration has not approved nutritional, herbal and homeopathic substances; however these have been used widely in Europe, China and the USA for years.

_______I understand that Dr. Kate Sydney is not a psychologist or psychiatrist. Counseling services are provided for the support of improved lifestyle strategies.

I do not expect Dr. Kate Sydney, and/or any allied health care provider to be able to anticipate and explain all of the risks and complications, and I wish to rely on the provider to exercise all judgment during the course of the procedure based on the known facts. I also understand that it is my responsibility to request that Dr. Kate Sydney explains therapies and procedures to my satisfaction. I further acknowledge that no guarantee of services have been made to me concerning the results intended from any treatment provided to me. By signing below I acknowledge that I have been provided ample opportunity to read this form or that it has been read to me. I have read and understand the above stated policies of Dr. Kate Sydney and will comply with them in all respects. I intend this as a consent form to cover the entire course of treatments for my present condition and any future conditions for which I seek treatment.

I hereby authorize and consent treatment.