You have the right to inspect and copy your protected health information:
I have the right to be informed about my health condition(s) and recommended treatment. This disclosure is to help me become better informed by discussing the potential benefits, risks and hazards involved.
I hereby request and consent to examination and treatment with licensed naturopathic physicians, or licensed acupuncturists who may serve as substitutes for one another in cases of my primary provider’s absence, hereafter called allied health care providers.
I understand that as part of the practice of naturopathic medicine evaluation and treatment may include, but are not limited to:
- Physical exams (e.g. general, musculoskeletal, EENT, heart and lung, orthopedic and neurological assessments)
- Common diagnostic procedures (e.g. venipuncture, pap smears, diagnostic imaging, laboratory evaluation of blood, urine, stool and saliva)
- Soft tissue and osseous manipulation (e.g. therapeutic massage, deep tissue massage, neuro-muscular technique, naturopathic/osseous manipulation of the spine and extremities), muscle energy techniques (e.g. BodyTalk, cranio-sacral therapy, others)
- Physiotherapeutic treatments (e.g. acupuncture, cupping, gua sha, moxa, therapeutic ultrasound, interferential, Pulsed Electromagnetic Frequency - PEMF)
- Dietary advice/therapeutic nutrition (e.g. use of foods, diet plans, nutritional supplements and intra-muscular vitamin injections)
- Trigger point injection therapy with vitamin substances
- 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)
- Counseling (including but not limited to visualization for improved lifestyle strategies)
- Over the counter or prescription medications, consistent with the Arizona Board of Naturopathic Physicians’ Formulary
Potential benefits: Restoration of the body’s maximal and optimal functioning capacity, relief of pain and other symptoms of disease, assistance with injury and disease recovery, and prevention of disease or its progression.
Potential risks: Pain, discomfort, blistering, minor bruising, discoloration, infections, burns, itching; loss of consciousness and deep tissue injury from needle insertions, pneumothorax, allergic reaction to prescribed herbs, supplements; soft tissue or bony injury from physical manipulations; aggravation of pre-existing symptoms.
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.
Notice to individuals with bleeding disorders, pacemakers, and/ or cancer: For your safety it is vital to alert your providers of these conditions.
Naturopathic doctors will only prescribe medications if they believe 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.
Naturopathic doctors are not psychologists or psychiatrists. Counseling services are provided for the support of improved lifestyle strategies. I do not expect the naturopathic physicians, and/or any allied healthcare providers 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 the doctor explain 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.
Acupuncture and Traditional Chinese Medicine: Potential risks of acupuncture include: bruising, numbness or tingling near the needling site that may last a few days, and dizziness or fainting. Bruising is a common side effect of cupping therapy. Unusual and rare risks of acupuncture include: spontaneous miscarriage, nerve damage, and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses disposable sterile needles and maintains a clean and safe environment. I understand that while this document describes the major risks of treatment, other side effects and risks may occur.
IV Therapy: Intravenous (IV) therapy is the administration of liquid substances directly into a vein. The word, “intravenous” literally means “within a vein.” The most commonly used vein is in the antecubital fossa, or the “inside” part of your elbow. Other commonly used veins are on the top of the hand or the forearm. Usually the IVs are delivered with a teflon-coated angiocatheter, but sometimes a metallic “butterfly” needle is utilized. These are both temporary types of devices. Our clinic does not offer IV therapy administered through a permanent port or central catheter.
General risks of IV therapy include, with decreasing frequency: discomfort during the infusion, bleeding, irritation of the vein, damage/inflammation (phlebitis) or scarring of the vein, hematoma (bleeding under the skin; a bruise) at the IV site or site of needle stick, blood pressure changes, dehydration/thirst, hypoglycemia/low blood pressure, headache/dizziness, electrolyte changes, blood clot, or death. It is also possible that there is a failure to achieve a substantial benefit. It is necessary to list these potential risks, however, the vast majority of patients have no adverse effects at all when undergoing IV therapy.
By signing and submitting this form I acknowledge that I have been provided ample opportunity to read this document or that it has been read to me.
I understand all of the above and give my oral and written consent to the evaluation and treatment to cover the entire course of treatments for my present condition and any future conditions for which I seek treatment.