INFORMED CONSENT

I understand that Dr. Todd LePine is board certified in Internal Medicine and certified in Functional Medicine. Functional Medicine focuses on nutritional and hormonal imbalances, diet, exercise, environmental influences and psycho-social stressors based on the premise that they directly relate to the development and maintenance of illness. Functional Medicine evaluates these influences and then specifically tries to remedy them to facilitate the process of self healing. It encourages patients to give up negative lifestyle patterns and establish more positive ones regardless of the type of medical problems.

The Functional Medicine model is Personalized, Patient-centered, Proactive and Participatory.  It is a science-based, systems biology approach that empowers patients and practitioners to work together to address the underlying causes of disease and promote optimal wellness. It requires a detailed understanding of each patient’s genetic, biochemical, and lifestyle factors and leverages that data to direct personalized treatment plans which can help lead to improved patient outcomes.

By addressing root cause(s), rather than just symptoms, Functional Medicine doctors become oriented to identifying the complexity of disease. They may find one condition has many different causes and, likewise, one cause may result in many different conditions. As a result, Functional Medicine treatments target the unique manifestations of disease in each individual. 

The defining principles of Integrative Functional Medicine are:

• The patient and practitioner are partners in the healing process.
• All factors that influence health, wellness and disease are taken into consideration, including body, mind, spirit and community.
• Providers use all healing sciences to facilitate the body’s innate healing response.
• Effective interventions that are natural and less invasive are used whenever possible and often as first line treatments, following the Hippocratic oath of “primum non nocere” or “first do no harm.”
• Good medicine is based in good science. It is inquiry driven and open to new paradigms.
• Alongside the concept of treatment, the broader concepts of health promotion and the prevention of illness are paramount.
• The care is personalized to best address the individual’s unique conditions, needs and circumstances. Practitioners of integrative Functional Medicine exemplify its principles and commit themselves to self-exploration and self-development.
   

As a patient I have the right to be informed about my condition and the available options recommended for my care. This disclosure is to help me become better informed so I may make the decision to give or withhold my consent as whether or not to undergo an Integrative Functional Medicine approach to diagnosis and treatment of my condition(s) having had the opportunity to discuss potential benefits, risks, and hazards involved.

 

I hereby request and voluntarily consent to examination and/or treatment or recommendation for treatment using an Integrative Functional Medical approach, which may include the following treatments: vitamins, minerals, amino acids, supplements, IV therapies, ozone therapies, injections, detoxification treatment modalities, lab testing, nutrition recommendations, etc. for me (or for the patient named below, for whom I am legally responsible).

I understand that the U.S. Food and Drug Administration has not fully evaluated or approved nutritional, herbal and homeopathic supplements, compounded IV’s/injections, ozone therapies, bio-identical hormone replacement therapies; however, they have been widely used in Europe and the U.S. for years. I understand that, as with drugs, hormones, nutritional supplements, herbal, and homeopathic remedies, ozone, nutritional IV therapies and injections may exhibit some side effects in certain sensitive individuals, may interact with certain allopathic medications or lab tests, or show symptoms, due to certain pre-existing disease conditions. I do not expect the medical provider to be able to anticipate and explain all risks and complications, and I wish to rely on the medical provider to exercise judgment in recommending the dietary supplements, medications, and treatment, that the medical provider feels at the time, based on the facts then known, is in my best interest. I understand that if I do not take the supplements or treatments as recommended, I may not get the desired result or may increase chances for an adverse effect.

It is my responsibility to keep my medical provider up to date with all of the current medications and supplements that I am taking, so that he can make the best-informed recommendations for my care.

I have the opportunity to ask questions and discuss with Dr. Todd LePine to my satisfaction:

• my suspected diagnosis or condition 

• the nature, purpose, and potential benefit of the proposed 
care 

• the inherent risks, complications, potential hazards, or 
side effects of the recommended treatment(s) 
• the probability or likelihood, of success
• reasonable available alternatives to the proposed treatment(s)
• the possible consequences if treatment or advice is not followed and/or nothing is done

I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from the treatment.

I understand that an integrative Functional Medicine, evaluation and treatment may include, but is not limited to: collecting specimens for laboratory evaluation, ordering diagnostic imaging, prescription of certain medications and/or nutritional supplements, and/or recommendations for IV therapy, hyperbaric oxygen, medical ozone treatment/therapy, bio-identical hormone replacement therapy, injections, counseling, dietary therapies, infrared sauna, or other alternative remedies.

I understand that Dr. Todd LePine has been trained in a diverse range of diagnostic and treatment options. I understand that Dr. Todd LePine is highly specialized and bases treatment modalities upon evidence-based clinical medicine, including Functional Medicine and integrative medicine principles. As such, he may recommend different tests; may interpret standard tests differently; may propose different treatments, or may administer standard treatments differently than most conventional physicians as many perspectives exist in medicine and in some cases there may be a disagreement among qualified medical experts, e.g. a “normal lab” value may not equate with an optimal lab value.  Care rendered may therefore be seen by some as outside the standard of care or as "medically unnecessary." Diagnosis and treatment may include some services that are considered non-traditional, non- conventional or alternative medicine. These services may not be recognized as standard medical practices and may be considered by insurance companies to be experimental or investigational. Along with training, the rationale for these differences is based on clinical experience and ongoing continuing education in evidence based Functional and Integrative medicine. In general, Dr. LePine's treatment recommendations have a good risk/benefit ratio, i.e. low risk, good benefit. 

By signing this form below, I acknowledge I have carefully read, or have had read to me, and understand the above consent. I give my permission and consent to care and authorize medical treatment by Dr. Todd LePine, and I am fully aware of what I am signing. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment and I may ask my physician for a more detailed explanation.

 

 

 

I certify by signing below that I have read the foregoing Informed Consent, discussed the issues noted above, had the opportunity to ask questions, and agree and accept all of the terms and conditions above.