NATUROPATHIC ASSESSMENT AND THERAPEUTIC INFORMED CONSENT
Naturopathic medicine is, as the name implies, the treatment and prevention of diseases by natural means. Naturopaths assess the whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. Gentle, non-invasive techniques are generally used in order to stimulate the body’s inherent healing capacity.
A number of different approaches are used in order to treat the person. Diet and nutritional supplements, botanical medicine, homeopathy, oriental medicine and acupuncture, hydrotherapy, physical medicine and lifestyle counseling are the mainstays of naturopathic medicine.
I, ______(print name) the undersigned, do hereby acknowledge that I have been informed and understand for myself or child (if under 16 years old): If you are signing on behalf of a minor please state their name: ______(patient’s name)
1. the recommended procedure(s)/plan and have discussed to my satisfaction, with Dr. Vicki Comeau, ND
2. the therapeutic procedure(s)/plan with respect to the expected benefits, potential risks, side effects, financial costs, and the likely consequences of not having the procedure(s)
3. that I have other treatment options offered to me by the allopathic medical profession (drugs, chemotherapy, radiation and surgery), and by other Health Care Professionals (i.e. Chiropractic and Massage Therapy) and the likely side effects and consequences of not having the procedure(s)
4. that Dr. Vicki Comeau, ND uses the BioEnergetic Stress Test (B.E.S.T) as an assessment aid in order to detect energetic imbalances within the body and that this device is NOT for the purposes of diagnosing any set illness or condition
As Naturopathic Medicine is a holistic approach to health, lifestyle is considered relevant to most health problems. Dr. Vicki Comeau, ND will help identify risk factors and make recommendations with the goal to optimize your physical and emotional environment.
I understand that Dr. Vicki Comeau, ND will take a thorough case history, do a screening physical examination, which may include a breast exam on females, and request blood work or other laboratory testing (i.e. saliva, urine, stool or others) as needed. If your case requires internal examinations you will be referred back to your medical doctor.
Even the gentlest therapies have their complications, especially in certain physiological conditions such as pregnancy and lactation, or in very young children. Some therapies must be used with caution in certain diseases such as diabetes, heart, liver or kidney disease. It is very important therefore, that you inform Dr. Vicki Comeau, ND immediately of any disease process that you are suffering from, or if you are pregnant, suspect you are pregnant or you are breast feeding.
There are some health risks to treatment by Naturopathic Medicine. These include, but are not limited to:
o Aggravation of pre-existing symptoms;
o Allergic reactions to supplements or herbs; PLEASE TURN OVER à
o Pain, bruising or injury from intramuscular injections or acupuncture;
o Fainting or puncturing of an organ with acupuncture needles, accidental burning of skin from the use of moxa;
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 is required by law. I understand that I may request copies of any testing done with Dr. Vicki Comeau, ND of which an appropriate fee will be charged. I understand that information from my record may be analyzed for research purposes, and that my identity will be protected and kept confidential. I understand that Dr. Vicki Comeau, ND will answer any questions I have to the best of her ability. I understand that results are NOT guaranteed, nor do I expect Dr. Vicki Comeau, ND to be able to anticipate and explain all the risks and complications that may arise. I will rely on her to exercise judgment during the course of the procedure which she feels at the time is in my best interests, based upon the facts that I have informed her of at that time.
Although I am here to seek Dr. Vicki Comeau, ND’s professional medical advice and treatment suggestions, I understand that I need to take responsibility for my own health and do my part in complying with treatment recommendations in order to achieve the best results. If I do not follow the treatment as prescribed, I understand that it may take longer to reach my health goals and that an accurate re-evaluation of my case cannot be made at the following visit without taking that into consideration.
I understand the following are all methods used by Dr. Vicki Comeau, ND for the purposes of assessment and or therapeutic treatment:
o Nutritional/Diet – First Line Therapy Program
o Botanical Medicine – i.e. herbal tinctures, creams, salves, ointments, gels etc.
o Counseling
o Exercise recommendations
o Extremity adjustments (i.e. ankles, knees, toes, fingers, elbows)
o Functional Medicine – assessment focused on the biochemical uniqueness of the individual patient
o Hydrotherapy
o Ion Cleansing
o Contact Reflex Analysis (CRA) – analysis of the body’s structural, physical and nutritional needs
o Homeopathy (including Unda drainage remedies and single homeopathics)
o Traditional Chinese Medicine and Acupuncture
o Supplements (Nutraceuticals), Lifestyle Changes
o Matrix Repatterning
In the event of a medical emergency or if I choose to follow conventional medical therapy I am advised to seek conventional medical care at a hospital or any medical doctor’s office.
I have read the above information and with this knowledge, I voluntarily consent my informed consent to the diagnostic and therapeutic procedure(s) mentioned above, except for: (please list exceptions, if any)
______
I understand that I may withdraw my consent and discontinue participation in these procedure(s) at any time.
Signature of Patient or Legal Guardian ______
If patient is under the age of 16 yrs old Guardian must sign. Date ______2/2