INFORMED CONSENT FOR NATUROPATHIC CARE
I understand that the practice of naturopathic medicine requires taking a thorough case history, and may require a physical exam. In some cases, diagnostic testing including the collection of blood, urine and/or saliva may be
I confirm that the information I have provided to Dr. Nora Shilo is complete and inclusive of all health concerns including the possibility of pregnancy and use of all current medications, including over-the-counter drugs.
I understand that naturopathic medicine carries a risk of complications and that a resolution of symptoms is not guaranteed. Health risks ofsome naturopathic treatmentsinclude, but are not limited to: Temporary aggravation of pre-existing symptoms, Allergic reactions and other adverse effects to botanical medicines or supplements, Pain, fainting, bruising or injury from venipuncture, acupuncture or cupping treatments, Muscle sprain, ligament strain,swelling and/or pain from spinal manipulation.
I confirm that I have the ability to accept or reject the recommended treatment at my own free will.
I understand that I have the ability to seek and/or continue medical care from another qualified healthcare practitioner. I recognize that I am encouraged to speak freely regarding the treatments received and recommendations made by Dr. Nora Shilo.
I understand that a record of my visits and medical history will be kept, that this record will be strictly confidential and will not be released to any persons without my written consent. If Dr Shilo needs to communicate/collaborate with my other healthcare practitioners about my case, only necessary information will be shared.
I have read and understood the fee schedule and I acknowledge that these services are only partly covered by MSP* and I am responsible for payment of goods and services in full at each visit.
I understand that there is a cancellation fee (full fee) for appointments missed without notice or cancelled with less than 24 hours notice. I acknowledge that if I arrive late for my scheduled appointment, the visit will be shortened to ensure that other patient visits are kept on time.
I understand that Dr. Nora Shilo reserves the right to determine which cases fall outside her scope of practice, in which case an appropriate referral will be recommended.
CONSENT AND AUTHORIZATION FOR INTRAVENOUS THERAPY PROCEDURES
PHYSICIAN PERFORMING PROCEDURE: Dr. Nora Shilo, ND
1. You have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not to be performed until you have had an opportunity to receive such information and to give your informed consent.
- The procedure involves inserting a needle into your vein, and injecting the formula by your physician.
- Alternatives to intravenous therapy are oral supplementation and/or dietary and lifestyle changes.
- Rare risks of intravenous therapy include: i. Discomfort, bruising and pain at the site of injection. ii. Inflammation of the vein used for injection (phlebitis). iii. Severe allergic reaction, anaphylaxis, cardiac arrest, and death.
- Benefits of intravenous therapy include: i. Injectables are not affected by gastrointestinal system or disease. ii. Total amount of infusion is available for the tissues and organs. iii. Nutrients enter cells by means of a high concentration gradient for maximum nutrient uptake. iv. Higher doses of nutrients can be given than possible by oral dosing without intestinal irritation.
2. You have the right to consent to or refuse any proposed treatment at any time prior to its performance. Your signature on this form affirms that you have given your consent to receiving intravenous infusions deemed safe and efficacious by your physician.
3. The procedures will be performed by or under the direction of the physician named above with qualified medical assistants (if required).
4. As bags for IV therapies are prepared on an as needed basis and for the individual patient, 24 hours notice MUST be given for a cancelled appointment. Without adequate notice, you will be charged for the treatment.
Your agreement means that:
a) You understand the information provided on this form and agree to the foregoing
b) The procedure(s) set forth above have been adequately explained to you by your physician
c) You have received all the information and explanation you desire concerning the procedure
d) You authorize and consent to the performance of the procedure(s)
