Treatment and Care
I hereby request that Bodies By Blake provide advice, consultations, and treatment. I acknowledge that certain treatments offered by Bodies By Blake may be considered "alternative" by the conventional medical community and may involve inherent risks. I understand that it is not possible for Bodies By Blake to anticipate all risks and complications, and I rely on their professional judgment to act in my best interest based on the information available at the time of treatment.
I understand that the treatments provided by Bodies By Blake are intended to complement, not replace, the care provided by traditional medical doctors or primary care physicians. These treatments are intended to enhance my overall health and quality of life.
I further acknowledge that the U.S. Food and Drug Administration (FDA), the Medicines and Healthcare products Regulatory Agency (MHRA), and the Therapeutic Goods Administration (TGA) have not fully evaluated or approved all nutritional, herbal, and homeopathic supplements, compounded IVs/injections, ozone therapies, and bio-identical hormone replacement therapies. Nevertheless, these therapies have been widely utilized globally for many years. As with any therapeutic intervention, there are potential risks, including side effects, interactions with conventional medications or lab tests, or exacerbation of pre-existing conditions. I do not expect Bodies By Blake to foresee all possible risks and complications, and I entrust their professional judgment in recommending dietary supplements, medications, and treatments that they deem appropriate based on the available information. I recognize that failure to adhere to recommended supplements or treatments may result in suboptimal outcomes or an increased risk of adverse effects.
Dietary Recommendations and Nutritional/Herbal Supplements
Bodies By Blake may provide dietary recommendations and suggest the use of nutritional and herbal supplements to support the physiological and biomechanical processes within the human body. While these recommendations may have specific therapeutic objectives, their primary purpose is to support metabolic function. Nutritional supplements may be safely used in conjunction with pharmaceutical medications, though some interactions may occur. Therefore, it is imperative to keep all healthcare providers fully informed of all medications, nutritional supplements, herbs, or hormones being taken.
We recommend sourcing only high-quality products from reputable manufacturers that we have thoroughly vetted through research and experience. Although there is no obligation to purchase these products through us, we cannot guarantee similar quality or efficacy from external sources.
Privacy Practices and E-mail Correspondence
I consent to the use of my Patient Health Information by Bodies By Blake for the purpose of treatment and coordination of care. I understand that I have the right to review and obtain a copy of my health records. The staff at Bodies By Blake will take all necessary precautions to ensure that my records are not accessed by unauthorized individuals. I also authorize correspondence from my practitioner to be sent to me via e-mail. I am aware that e-mail correspondence involving confidential health information carries inherent risks.
Risks:
- General E-mail Risks: E-mail communications can be broadcast worldwide and received by both intended and unintended recipients. Recipients may forward e-mails to others without the sender's consent or knowledge. E-mails can be easily misaddressed or falsified, and backup copies may exist even after deletion by the sender or recipient.
- Specific E-mail Risks: E-mails that include diagnostic or treatment information must be considered part of the protected personal health information. All individuals with access to this information will have access to the e-mail messages. Patients who send or receive e-mails from their place of employment risk having their employer access their e-mails.
Bodies By Blake will incorporate e-mail communications concerning diagnosis or treatment into the patient’s protected personal health information and will treat such communications with the same level of confidentiality as other protected health information. While Bodies By Blake will employ reasonable measures, including encryption where feasible, to protect the security and confidentiality of e-mail and internet communications, I acknowledge that absolute security and confidentiality cannot be guaranteed.
It is my responsibility to keep my healthcare provider informed of all current medications and supplements I am taking to enable the provider to make well-informed recommendations for my care.
Informed Consent
I have had the opportunity to discuss, to my satisfaction, the following with my provider:
- My suspected diagnosis or condition
- The nature, purpose, and potential benefits of the proposed care
- The inherent risks, complications, and potential side effects of the treatment or procedure
- The likelihood of success
- Reasonable alternatives to the proposed treatment or procedure
- The possible consequences of declining treatment or advice
I understand that the providers at Bodies By Blake have extensive training in a wide range of diagnostic and treatment options. Bodies By Blake practices evidence-based medicine, including holistic principles. As such, they may recommend different tests, interpret standard tests differently, propose alternative treatments, or administer standard treatments in a manner that may differ from conventional physicians. I understand that care rendered by Bodies By Blake may be viewed by some as outside the standard of care or medically unnecessary. Diagnosis and treatment may include services considered non-traditional, non-conventional, or alternative, which may not be recognized as standard medical practices and may be deemed experimental or investigational by insurance companies. The rationale for these differences is based on clinical experience and continuous education in evidence-based integrative medicine.
Legal Considerations
- Jurisdiction Clause: This agreement shall be governed by the laws of Mississippi. Any disputes arising from this agreement shall be resolved in the courts of this jurisdiction.
- Severability Clause: If any provision of this agreement is deemed invalid or unenforceable by a court of competent jurisdiction, the remaining provisions shall remain in full force and effect.
- Right to Revoke Consent: I understand that I have the right to revoke this consent at any time by providing written notice to Bodies By Blake. Revocation of consent will not affect any actions taken before the receipt of the revocation.
By signing this form, I affirm that I have carefully read and fully understand the terms of this consent. I acknowledge the risks and responsibilities associated with the proposed treatment and the use of e-mail correspondence. I consent to receive care and authorize medical treatment by Bodies By Blake and its staff. I am fully aware of what I am signing and intend for this consent form to cover the entire course of treatment for my present condition and any future conditions for which I seek treatment. I understand that I may request further explanation from my physician at any time.
I further acknowledge that no guarantees or assurances have been made to me regarding the results of the treatment.