INFORMED CONSENT FOR TREATMENT
The purpose of this informed consent form is for Collaborative Natural Health Partners to provide you with written information regarding naturopathic medicine, integrative and functional medicine services and the potential risks, benefits and alternatives so that you may make an informed decision about whether to proceed with evaluation and treatment. This material serves as a supplement to the discussion you have with your Collaborative Natural Health Partners’ doctor about any potential treatment or course or care.
By signing below, you acknowledge and agree to the following:
I understand that the doctors of Collaborative Natural Health Partners are licensed providers in Connecticut, and some may be licensed in other states.
Naturopathic physicians are trained as specialists in integrative medicine. Naturopathic physicians are experts in advanced diagnostic testing, nutrition, botanicals and supplements. Some of the naturopathic physicians at Collaborative Natural Health Partners are also trained in craniosacral therapy, acupuncture, bowen and other specific modalities.
Osteopathic physicians are Board certified in family medicine with additional training in osteopathic manipulation. These doctors are primary care doctors who are open to integrative medicine and can act as your primary care doctor but also can be an adjunctive care offering compounded prescriptive medications such as bioidentical hormones, low dose naltrexone, and glandular thyroid prescriptions.
I understand that all recommendations and treatments will be discussed with me before implementation, and that I am encouraged to ask questions including: my suspected diagnosis(es) or condition(s); the nature, purpose, and potential benefits of the proposed course of care and treatment; the potential risks, complications or side effects of the proposed treatment; reasonable available alternatives to the proposed treatment; and potential consequences if treatment or advice is not followed and/or nothing is done.
I hereby request and authorize the doctors of Collaborative Natural Health Partners to perform, order or recommend, as applicable, primary care, osteopathic medicine, functional medicine, and naturopathic medicine care (the “Integrative Medicine Services”) for me or the patient named below for whom I am legally responsible. All Integrative Medicine Services will be performed within the scope of the license of the provider providing care to me, and the providers of Collaborative Natural Health Partners provide the standard of care for primary medicine while offering natural alternatives when possible. Integrative Medicine Services may include, but are not limited to:
· Physical Exams and Common Diagnostic Procedures: Including physical exams and assessments, venipuncture/phlebotomy, Pap smears, ordering and interpreting conventional and functional laboratory testing of blood, urine, stool, saliva, and breath, and ordering diagnostic imaging as necessary.
· Minor office procedures: including dressing a wound, ear irrigation, suture removal, cryosurgery
· Dietary Advice and Therapeutic Nutrition: Including nutritional counseling, dietary plans, nutritional supplements (with vitamins, minerals and amino acids).
· Nutrigenomics: Review of genetic information for nutritional purposes. *I acknowledge that Collaborative Natural Health Partners does not employ any geneticists and none of the providers at Collaborative Natural Health Partners should be considered a substitute for a geneticist.
· Botanical/Herbal Medicines: Botanical substances and plant derivatives may be prescribed as teas, alcohol or glycerin tinctures, capsules, tablets, creams, or suppositories.
· Homeopathic Medicine: The use of highly dilute quantities of naturally occurring plants, animals, and minerals to gently stimulate the body's healing responses.
· Bioidentical Hormone Replacement Therapy and other Pharmaceutical Medications *(only prescribed by Osteopathic physicians): The use of bioidentical hormone replacement therapy, including thyroid medication, to help restore and balance hormone levels as needed. Other medications may be prescribed as necessary as permitted within the scope of practice of the provider.
· Physical Medicine and Acupuncture: The use of massage, stretching, resistance, and therapeutic exercise; craniosacral therapy (a gentle hands-on manual therapy used to balance the nervous system); visceral manipulation (a gentle hands-on manual therapy used to assess restrictions of the viscera); intersegmental traction, cupping and acupuncture.
· Hydrotherapy: Applications of hot and/or cold water via various forms (water bath, soaked towels, etc.), including peat bath and paraffin bath
· Lifestyle Counseling and Hygiene: Recommendations to promote improved lifestyle strategies including exercise/movement, stress management practices, sleep and environment.
I understand the providers at Collaborative Natural Health Partners are not psychologists or psychiatrists and any counseling is for support of improved lifestyle strategies only. I also understand the U.S. Food and Drug Administration has not approved nutritional, herbal, and homeopathic substances to treat specific diseases.
No Guarantee and Patient Responsibility: I understand that results from the Naturopathic Medicine Services are not guaranteed, and that Collaborative Natural Health Partners does not make any representations, promises, claims, warranties, assurances or guarantees that my medical problems or conditions will be helped or cured by undergoing any of Integrative Medicine Services. I understand that my failure to comply with any treatment recommendations and instructions may impede results, and that as with all existing methods of diagnosis and treatment, the Integrative Medicine Services have both benefits and risks.
Potential Benefits: Potential benefits may include restoration of health, mental well-being and the body’s maximal functional capacity; relief of pain and symptoms of disease; assistance in injury and disease recovery; and prevention of disease or its progression.
Potential Risks: Herbs, dietary supplements, and homeopathic remedies are generally considered safe. However, they may lack therapeutic effect or could cause allergic reactions or unpleasant side effects which could possibly range from mild to severe. The interactions between different herbs and between herbs and medications are also not always thoroughly understood. While unlikely, and while the Collaborative Natural Health Partners doctors are educated in herbal medicine including such interactions, it is possible to have an adverse reaction or experience a reduction or increase in the effect of other medications when taking herbs. These can have serious consequences for some medications, such as for the control of high blood pressure or blood sugar. Homeopathic medicines can potentially cause aggravation or worsening of current or pre-existing symptoms. There may also be other potential risks which may be discussed and clarified in separate consents specifically applicable to such treatments. For example: Potential risks of acupuncture include bruising, bleeding, numbness or tingling near the needling sites, and rarely nerve damage or infection. Potential risks of cupping include bruising and scarring.
I am aware that unforeseeable complications could occur, and that while the Collaborative Natural Health Partners doctors will make every reasonable effort to screen for contraindications to care, I do not expect them to be able to anticipate all possible risks and complications, and I wish to rely on them to exercise their professional judgment in recommending treatments that they feel, based on the facts then known, are in my best interest.
Following Doctor Instructions: I understand that for my safety, it is extremely important that I follow the instructions I receive with respect to dosing and administration of herbs, homeopathic medicines, nutritional supplements, and prescription medications. I understand that taking more than prescribed/recommended or self-treating with additional supplements or medications can be dangerous.
Complete Medical History: I understand that some treatments may be inappropriate and unsafe if I have certain health conditions or take certain medications or supplements, whether prescribed or over-the-counter. For this and other reasons, I understand that it is vital that I truthfully and accurately disclose all health information requested by my doctor as well as keep my doctor updated as to any changes, including any new treatments or procedures I am undergoing. I understand that failure to do so may negatively affect the safety of any treatments I receive, and there shall be no liability on the part of my doctor or Collaborative Natural Health Partners LLC should I fail to do so.
Notice Regarding Pregnancy and Breastfeeding: I understand that some treatments could present a risk during pregnancy and breastfeeding, and I agree to notify my Collaborative Natural Health Partners doctor immediately if I am pregnant, become pregnant, am planning to become pregnant in the next three months or if I am breastfeeding.
By voluntarily signing below, I certify that: I have read the foregoing Informed Consent for Treatment, or someone has read it to me. I understand the potential risks, benefits and alternatives, and I have had the opportunity to ask questions, and my questions have been answered. I hereby voluntarily consent and agree to receive Integrative Medicine Services with the Collaborative Natural Health Partners doctors, and I intend this Informed Consent to cover the entire course of my care with Collaborative Natural Health Partners. I understand that I am free to withdraw my consent and to discontinue participation in the Integrative Medicine Services at any time.