Do any members of your immediate family suffer from any of the following health conditions? If so, please explain in the text areas provided. Please specify which family member:
Does your child have any problems with any of the following body systems?
hereby authorize Dr. Marinaro/Dr. Froman to perform the following specificprocedures as necessary to facilitate my child’s diagnosis and treatment:
Common diagnostic procedures: e.g., venipuncture, radiology, laboratory, X-ray, paps
Minor office procedures: e.g., cleaning, dressing a wound, ear lavage, skin scraping
Medical use of nutrition: therapeutic nutrition, nutritional supplementation, and intramuscular vitamin injections.
Botanical medicine: plant substances may be prescribed as teas, alcohol-based tinctures, glycerites, capsules, tablets, creams or suppositories
Homeopathic medicine: the use of highly dilute quantities of naturally occurring plants, animals and minerals
Craniosacral Therapy, Visceral Manipulation: gentle forms of bodywork used to address back pain and other musculoskeletal complaints, headaches and organ dysfunction
Counseling: utilization of mental health counseling and techniques
Medical use of Ozone Therapy: therapeutic ozone gas administered to isolated parts of the body, combined with depuration in an ozone sauna and injected subcutaneously or intramuscularly to address chronic pain and infections
I recognize the potential risk and benefits of these procedures as described below:
Potential risks: allergic reactions to prescribed herbs and supplements, side effects of medications or vaccinations, aggravation of pre-existing symptoms, discomfort, pain, infection, burns, nausea, light headedness, inconvenience of lifestyle changes, injury from injections, venipuncture or procedures. Please notify Dr. Marinaro/ Dr. Froman if you experience any symptoms which may be secondary to the above procedures.
Potential benefits: restoration of health and the body’s maximal functional capacity without the use of drugs or surgery, relief of pain and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or it’s progression.
Notice to Pregnant Women: All female patients must alert the doctor if they know or suspect that they are pregnant as some of the therapies used could present a risk to the pregnancy.
With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by physician, or any personnel regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time.
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 or my representative or unless it is required by law. I understand that I may look at my medical record at any time and can request a copy of it by paying the appropriate fee. I understand that my medical record will be kept for a minimum of seven years, but no more than ten years after the last day of my visit. I understand that information from my medical record may be analyzed for research purposes, and that my identity will be protected and kept confidential. I understand that any questions I have will be answered by my practitioner to the best of his/her ability.
I understand that all sales of goods and services are final. Refunds for supplements up to 90 days after purchase (unopened items only).