• Treatment Consent Form

    Treatment Consent Form

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  • Intravenous Therapy Consent 

    I have been advised by my doctor that they recommend that I receive Intravenous and/or Intramuscular Supplement Injections.

    I understand that:

    • Intravenous and Intramuscular supplement injections may be outside the parameters of conventional medicine in Australia.
    • This treatment is supported by empirical knowledge and by research data.
    • This treatment is safe, is widely and successfully used by integrative medical practitioners in clinics across Australia and Internationally, and is ONLY prescribed and administered with the utmost care.
    • This treatment is NOT covered by Medicare and may not be covered by Private Health Insurance funds in Australia.
    • This treatment may NOT be regulated by the Therapeutic Goods Administration (TGA) and my doctor deems this treatment to be in my best interest.
    • Also that my doctor has made me fully aware of any risks associated with this treatment and has provided me with sufficient information to make an informed decision.

    I am agreeing to undergo this treatment of my own free will and consent and therefore exercise my right to discuss and choose any treatment/s made available to me.

    I have read, and understand, the contents of this document, that it is entirely my decision, and have not been coerced into accepting or declining the treatment available to me.

    Intravenous Vitamin C
    Benefits:
    Reduced risk for:
    Arthritis
    Asthma
    Cancer support
    Cardiovascular disease
    Lung disease
    Heart disease
    Stroke
    Cataracts
    Infections
    Chronic fatigue
    Glandular fever
    Hypertension
    Diabetes
    Fractures
    Surgical healing
    Heavy metal toxicity

    Possible Side Effects:
    Haemolysis for patients with G6PD deficiency if
    high dosage of IV Vitamin C given
    Headaches
    Nausea
    Vomiting
    Trembling
    Fatigue
    Mild Dehydration
    Local irritation of veins (eliminated by flushing at the
    end of IV)
    Symptoms usually last less than 24hours

    Intravenous Glutathione
    Benefits:
    Direct antixoidant
    Chelator of heavy metals (As and Hg)
    Crosses blood-brain barrier
    Recycles Vitamin C
    Helps with liver detoxification
    Helpful in fybromyalgia, chronic fatigue, hepatitis,
    Parkinson's Disease and cancer
    Synergises with Vitamin C

    Possible Side Effects:
    Chest pain
    Shortness of breath and other breathing issues
    Tightness in the throat and chest
    Allergic reaction-type symptoms (breaking out into
    hives, rashes, swelling up, excessive itchiness)
    Symptoms last less than 24hours

    Intravenous Magnesium
    Benefits:
    PMS
    Osteoporosis
    Restless legs
    Cardiovascular conditions — coronary artery disease
    Irregular heartbeat
    Mitral valve prolapse
    High cholesterol
    Metabolic syndrome
    Prevention of strokes
    CFS
    Nerve Pain
    Fibromyalgia
    Anxiety
    Cluster / Migrane headaches
    Asthma
    COPD
    ADHD
    Hypertension
    MS
    Premature labour

    Possible Side Effects:
    In patients with kidney problems, take with caution
    Heart block
    Given with caution
    Low blood pressure
    Confusion (only occasionally)
    Nausea (only occasionally)
    Upset stomach (only occasionally)
    In all cases, dosage can be reduced
    Symptoms last less than 24hours

    Intravenous Zinc
    Benefits:
    Help with Zinc deficiency
    Growth retardation
    Acne
    Alopecia
    Infertility
    Delayed wound healing

    Possible Side Effects:
    Hypotension
    Diarrhoea
    Vomiting
    Increased Amylase
    Symptoms last less than 24hours

    Intravenous Alpha Lipoic Acid
    Benefits:
    Diabetic neuropathy
    Any polyneuropathy
    Recycles Glutathione, Vitamins C and E
    Used in Krebs cycle for production of energy
    Neurodegenerative disorders (Parkinson’s, MS)
    Radiation damage
    Chemotherapy
    Heavy metal poisoning
    Sepsis Infections
    (With Vitamin C) increases killing effect of Vitamin C
    Increases Insulin sensitivity
    Useful in Hepatitis / Liver protection
    ALA + Vitamin C + Glutathione are synergistic in cancer cell killing

    Possible Side Effects:
    Hypotension
    Diarrhoea
    Vomiting
    Increased Amylase
    Symptoms last less than 24hours

    Intravenous EDTA / Chelation
    Benefits:
    Useful in treatment of Lead Poisoning
    Arteriosclerosis (Angina)
    Heart Attack, Stroke
    Claudication, Hypertension
    Tinnitus, Vertigo
    Peripheral Vascular Disease
    Rheumatoid & Osteoarthritis
    Diabetic complications
    Macular eye degeneration
    Heavy Metal Toxicity
    Summary: Chelation therapy with EDTA (Ethylenediamine-tetra-acetate) useful for all the above and heavy metal detoxification

    Possible Side Effects:
    Mild Nausea
    Shivering feeling inside
    Dizziness
    Headaches
    Hypoglycaemia


    Chelation drip consists of: 2.5grams of Mg, 10ml Sodium
    Bicarb, 15g Vitamin C, 1.5 gram EDTA, 10mg B1, 5mg B2,
    100mg B3, 20mg B5, 50mg B6


    I have been advised by my doctor to have iron injections due to my continuing symptoms, and my iron study results indicate that I may have iron deficiency anaemia which has been/is being investigated.

    The Dr. has informed me of the following side effects of iron injections:

    General
    Flushing, sweating, chills, fever
    Chest and back pain
    Local inflammation with inguinal lymphadenopathy
    Lower quadrant abdominal pain

    Hypersensitivity
    Anaphylaxis

    Gastrointestinal
    Nausea and Vomiting
    Central Nervous System
    Headache
    Dizziness

    Cardiovascular
    Faintness
    Syncope
    Tachycardia
    Hypotension
    Circulatory collapse

    Respiratory
    Bronchospasm with dyspoea

    Haematological
    Generalised lymphadenopathy

    Dermatological
    Rash
    Urticaria
    Angioneurotic edema

    Musculoskeletal
    Joint and muscle pain
    Arthralgia
    Sensation of stiffening of the arms, legs or face
    Staining of skin at site of injection

    Consent and Signing
    I have been advised by my doctor regarding the above benefits and side effects. The IV therapy has been suggested for my condition/health status and I understand there are no guaranteed outcomes of the treatment. I undertake this
    therapy of my own volition and accept the possibility of adverse side effects.
    I release my doctor from any legal responsibilities regarding the above treatment.

  • Biofield and Acutonics® Sound Treatment Disclaimer

    Biofield and Acutonics® Sound Treatments and their associated processes should not be relied upon as health, medical, psychological, or other professional advice of any kind or nature.

    Sound Treatments such as Biofield and Acutonics are non-invasive energy medicine* approaches for self-healing and relaxation that use sound waves produced by tuning forks and other sound-producing instruments on the body, and in the Biofield that surrounds the human body.

    Energy medicine methods, such as Biofield Tuning and Acutonics, are designed to assess where the body’s energies are blocked, trapped, or not in harmony and then correct the flow of these energies by aligning the body’s energies. The theory of energy medicine methods is that the flow and balance of the body’s electromagnetic and subtle energies are important for physical, spiritual, and emotional health, and for fostering overall well-being.

    You understand and accept that when utilising Sound Treatments the practitioner is not ‘diagnosing’ or ‘treating’ the physical body, which is the domain of the medical field and other allied healthcare professionals, but instead is connecting to the energy or subtle bodies of the client. You understand that there is a distinction between ‘healing’ using Sound Treatments and the practice of medicine or any other licensed healthcare practice.

    Although Sound Treatments appear to have promising emotional, spiritual, and physical health benefits, it has yet to be fully researched by the Western academic, medical, and psychological communities. Therefore, Sound Treatments may be considered experimental and the extent of their effectiveness, as well as their risks and benefits, are not fully known. Energy medicine methods such as Sound Treatments are considered ‘alternative’ or ‘complementary’ to promote relaxation.

    By signing below, I acknowledge the following:

    -I have honestly and comprehensively answered the questions asked on the intake form.

    -I have stated any relevant medical conditions and will keep my practitioner updated on my health should anything change.

    -It is my responsibility to notify my practitioner if any information provided changes.

    -If at any time during the session I feel uncomfortable I will inform my practitioner immediately.

    -I recognise and understand my responsibilities as a client.

    -I fully understand the information presented and voluntarily consent to treatment.

    -I fully understand that there is no guarantee or implied guarantee about the success of the treatments given.

    -I have read and understood the above descriptions of the treatment.

    -I understand the scope of practice of my practitioner.

     

    *Energy medicine is a collective term used that refers to a variety of energy techniques, processes, and methods based on the use, modification, and manipulation of energy fields that look at imbalances within an individual’s energy system as well as the energetic influence of thoughts, beliefs, and emotions on the body.

  • CONSENT FORM FOR WHOLE-BODY HYPERTHERMIA TREATMENT

    I, the undersigned, hereby give my informed consent to undergo whole-body hyperthermia (WBHT) treatment at WillowVale Clinic. I have been provided with detailed information about the procedure, its potential benefits, risks, and alternatives.

     

    Purpose:
    Whole-body hyperthermia is a medical procedure involving the controlled elevation of body temperature for therapeutic purposes. The aim is to help increase the body core temperature up to 40C. 

     

    Benefits:
    I understand that the potential benefits of whole-body hyperthermia may include increasing the efficacy of chemotherapy and radiation therapy and improving the functioning of my immune system.

     

    Risks and Discomforts:
    I am aware that the procedure carries certain risks and discomforts, including but not limited to dehydration, changes in blood pressure, skin reactions, and heat / thermal injury. The medical staff has explained these potential risks, and I have had the opportunity to ask questions for clarification.

     

    Alternatives:
    I understand that alternative treatments or procedures may exist and have been discussed with me. I have chosen whole-body hyperthermia after considering these alternatives.

     

    Confidentiality and Records:
    I acknowledge that my medical records related to Whole Body Hyperthermia will be kept confidential, in compliance with applicable laws and regulations.

     

    Voluntary Participation:
    I affirm that my participation in Whole Body Hyperthermia is voluntary, and I reserve the right to withdraw my consent at any time without affecting my current or future medical care.

     

    I have had the opportunity to discuss any concerns or questions with my healthcare provider, and all my queries have been addressed to my satisfaction.

     

    I have read and understood the information provided in this consent form. I willingly consent to undergo Whole Body Hyperthermia at WillowVale Clinic.

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