I request to be evaluated by the medical staff of the Carolina Center for Integrative Medicine, PA.
I understand that Integrative Medicine is not a traditional medical practice and may be considered to depart from acceptable and prevailing medical practices, but Dr. Pittman and his staff believe it is a beneficial approach. This request and consent to participate in treatment indicates that I understand Carolina Center is not my primary care practice nor do I expect this to be the case. I will continue my primary and specialty care with other healthcare professionals, and I will advise them of my treatment at The Carolina Center for Integrative Medicine.
I consent to the treatment by the Carolina Center provider for my symptoms, which I described in the Medical History Form and other documents I provided prior to my initial visit. I understand that the Carolina Center providers will take a detailed medical history, will perform a physical examination as indicated, will recommend laboratory tests to assess my general health status and medical condition so that they may make recommendations for treatments to address the symptoms which I have indicated.
I understand that if at any time I do not believe the treatment protocols are effective or do not wish to continue, I may withdraw from treatment. Furthermore, I understand that traditional medical insurance and Medicare/Tricare/Medicaid will likely not pay for services provided by The Carolina Center for Integrative Medicine. Any payments received should only be viewed as fortuitous and not be expected on an ongoing basis as insurance companies may change their opinion about coverage.
It is understood that this is not informed consent to any of the individual recommended treatment protocols, which will be made independently, but it is a general consent to this Integrative Practice. I consent to and request to be evaluated at The Carolina Center for Integrative Medicine.