Naturopathy

INFORMED CONSENT FOR NATUROPATHIC SERVICES

Naturopathic medicine is the treatment and prevention of diseases by natural means. Naturopathic Doctors assess the whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. Treatments include diet, nutrition, botanical medicine, acupuncture, physical manipulation, hydrotherapy, homeopathy, counseling, and Intravenous Therapy. These gentle, non-invasive techniques are generally used in order to stimulate the body’s inherent healing capacity. The Naturopathic doctor will take a thorough case history, perform a physical examination and may take blood and urine samples. If your case requires and with your consent, the physical exam may include more specific examinations such as gynecological or prostate.

 

DEAR PATIENT,

 

As a patient you will receive information about your diagnosis and/or treatment, alternative courses of action, the material effects, costs, expected benefits, risks, side effects and in each case the consequences of not having the diagnosis and/or treatment acted upon.

 

There are some slight 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 parenteral therapies
  • Fainting with acupuncture needles or parenteral therapies or puncturing of an organ with acupuncture needles
  • Muscle strains and sprains, disc injuries from spinal manipulation

 

I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by myself when law requires it. I also understand the potential risks to treatments as mentioned above.

 

I understand that my Naturopathic Doctor will answer any questions that I have to the best of her ability. I understand that the results are not guaranteed. I do not expect the Naturopathic Doctor to be able to anticipate and explain all risks and complications. I will rely on the Naturopathic Doctor to exercise judgment during the course of the procedure which they feel at that time is in my best interests, based on the facts then known. With this knowledge, I voluntarily consent to diagnostic and therapeutic procedures mentioned above. I also confirm that I have the ability to accept this care of my own free will and choice.

 

 

It is our policy that 24 hours notice is required to cancel/reschedule an appointment otherwise a fee of $50.00 will be charged.

 

I understand that the Naturopathic Doctor will not disclose or discuss test results over the phone or email. I understand that this office will not provide treatment options or change the treatment protocol over email or over the phone without an appointment. We may send out clinic newsletters to patients who provide an email. We may also contact you over email to change or modify an appointment. I understand that the Lakeside Clinic is not a Walk In Clinic and appointments are necessary.

 

I declare that I have received a full and complete explanation of the treatment or services that I may receive with my naturopathic doctor and hereby authorize and consent to treatment. I agree to pay my full account at the time of each visit or treatment, including fees for services, cost of supplements and remedies, cost of laboratory tests, administrative fees as well as other applicable fees.

 

It is very important that you inform your Naturopathic Doctor immediately of any disease process that you are suffering from and any medications/over the counter drugs that you are currently taking. Please advise your Naturopathic Doctor immediately if you are pregnant, suspect you are pregnant or if you are breast-feeding.

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Personal Information

Health Care Providers

Main Health Concerns

What are your health concerns, in order of importance to you?

MEDICAL INFORMATION

Please list prescribed and over the counter medications you are currently using or have used in the last 5 years.Include dose, frequency and duration of use.

Please list names and brands of all current vitamins, minerals, botanicals and other natural health products you are currently using. Include dose, frequency and duration of use.

FAMILY MEDICAL HISTORY

Please indicate if any of your family members have experienced the following:

ENVIRONMENTAL EXPOSURES