I hereby request and consent to the performance of naturopathic treatments and other procedures within the scope of the practice of naturopathic medicine on my (or on the patient named below, for I am legally responsible) by the naturopathic doctor named below and/or other licensed naturopathic doctors who or in the future treat me while employed by, working or associated with or serving as back-up for the naturopathic doctor named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.
I understand that methods of treatment may include, but are not limited to: nutrition, botanical medicine, physical medicine and acupuncture. I understand that the herbs, remedies and supplements should be consumed according to the instructions provided orally and in writing. I will immediately notify the doctor listed below of any unanticipated or unpleasant effects associated with the herbs, remedies or supplements.
Even the gentlest therapies have their complications. Certain conditions such as pregnancy, lactation, those on multiple medications or who have certain diseases such as diabetes, heart, liver or kidney disease, or are very young need to proceed
with caution in treatment. It is very important that you inform your naturopathic physician immediately of any disease process that you are suffering from, if you are on any medication or over the counter drugs, or if you are pregnant, suspect you are
pregnant, actively attempting to become pregnant or if you are breast-feeding.
There are some potential health risks to treatment by Naturopathic Medicine. These include but are not limited to, aggravation of pre-existing symptoms, allergic reactions to supplements or herbs, pain, bruising or injury from Venipuncture, Acupuncture or Cupping, fainting or puncturing of an organ with Acupuncture needles, accidental burning of the skin from the use of Moxa, Cupping, and Moist heat, muscle strains, sprains or disc injures from spinal manipulation, the potential for stroke in neck manipulation (tests will be done to screen for this possibility. Clinical research has shown that stroke-like occurrences are rare, occurring approximately 1 in 1.5 million manipulations).
I do not expect the naturopathic doctor to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the naturopathic doctor to exercise judgment during the course of treatment which the naturopathic
doctor thinks at the time, based upon the facts then known is in my best interest. I understand that results are not guaranteed.
I understand the clinical staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent.
By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of naturopathic medicine and other procedures, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions(s) for which I seek treatment.