Informed Consent

Please read this information carefully, and ask if there is anything that you do not understand.

While acupuncture, Chinese Medicine, acupoint injection therapy, nutritional and herbal therapies, and other treatments provided by Yinstill Reproductive Wellness have proven to be highly effective in correcting conditions and maintaining overall well-being, practitioners are required to advise patients that there may be some risks. Although practitioners cannot anticipate all the possible risks and complications that may arise with each individual case, you should be aware that the following side effects can occur. If there are particular risks that apply in your case, your practitioner will discuss these with you.

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. Gentle, non-invasive techniques are generally used in order to stimulate the body’s inherent healing capacity. Your naturopathic doctor will take a thorough case history, and may perform a physical examination including a breast exam, and take blood and urine samples. If your case requires, the physical may include more specific examinations such as gynecological, rectal, prostate or genital exams.

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. Our naturopathic doctors are trained to handle emergencies should the need arise.

ACUPUNCTURE is a technique utilizing fine sterile disposable stainless steel needles inserted at specific points in the body to cause a positive response in order to correct various ailments.

What are the possible side effects of acupuncture?

•  Drowsiness can occur in a small number of patients, and if affected, you are advised not to drive;
•  Minor bleeding or bruising can occur from acupuncture;

– In less than 3% of patients, symptoms may become worse before they improve for 1-2 days following treatment. This is usually a good sign. Please advise your acupuncturist if worsening of symptoms continues for more than 2 days;

•  Fainting can occur in certain patients, particularly at the first treatment;
•  What are the possible side effects of Chinese Medicine and other treatments provided at this clinic?
•  Bruising (looks like a circular hickey) is a common side effect of cupping
•  Pneumothorax (collapse of a lung) is possible if the practitioner actually penetrates the lung organ.
•  Minor burn blisters may occur due to moxibustion therapy

NUTRITIONAL AND HERBAL THERAPIES include substances used for the prevention and treatment of disease. Common side effects include gastrointestinal upset, diarrhea, and although rare, possible allergic reactions. It is your responsibility to inform the treating practitioner of any allergic reactions you may have had at any time in the past. Some may be toxic in large doses or inappropriate during pregnancy.

INJECTION THERAPIES involve the use of intravenous, intramuscular, and intradermal injection of nutrients & substances including amino acids, vitamins, minerals, and sterile biological substances. I understand that these therapies may be used, upon my request and consent to treat my condition. Side effects are rare, but may include allergic reactions to medicinal or other substances contained in the compounds, pain or other sensations at the site of the needle insertion, and bruising. Other rare risks include wheezing, irregular heartbeats, rapid heart rhythms, infiltration (IV fluid infusing into the extravascular tissue), vasovagal reactions (dizziness, lightheadedness, fainting), and elevated or reduced blood pressure.  I understand the nature of the proposed procedure and the risks associated.

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

Is there anything else your practitioner needs to know?

Apart from the usual medical details, it is important that you let your practitioner know:

•  If you have ever experienced a fit, faint, or other odd detached sensations;
•  If you have a pacemaker or any other electrical implants;
•  If you have ever had any allergic reactions;
•  If you have a bleeding disorder;
•  If you are taking anti-coagulants (blood thinners) or any other medication;
•  If you have damaged heart valves or have any other particular risk of infection.
•  If you have not eaten in the last few hours.

 

STATEMENT OF CONSENT

I understand that I will have an opportunity to discuss with the acupuncturist and/or with other office or clinic personnel, the nature of treatment and other procedures. I understand the results may not be guaranteed. I understand that I will be draped at all times and the areas undraped will be secure to insure there is no indecent exposure. If undraping my gluteals is significant in the treatment I do understand that it is part of the therapy.

The clinic does not guarantee treatment results. My practitioner will explain to me the exact nature and indication of any treatment provided and will answer any questions I may have. My practitioner will make the appropriate referral for me when necessary. I am free to withdraw my consent and discontinue treatment at any time.

I understand the risks associated with naturopathic medicine and provide my informed consent to treatment with Dr. Ross which may include but is not limited to: clinical nutrition, dietary and lifestyle counselling, IV therapy, acupuncture, pharmaceutical prescriptions, and any other treatment that may be indicated in my specific case.

I consent to having treatments and procedures from Yinstill Reproductive Wellness. I understand that there have been no warranties, assurances, or guarantees of a successful treatment made to me. I understand that treatment will be most effective if I follow all recommendations given to me. I have read the possible risks of treatment outlined above, but do not expect the practitioner to be able to anticipate and explain all possible risks and complications of treatment and will not hold the practitioner or the clinic at fault if unlikely or extraordinary events occur while I am on their property or in their care. I also understand that I can refuse treatment at any time. I wish to rely on my practitioner to exercise judgment during the course of treatment which, based upon the facts then known, is in my best interests. I understand the practitioner may review my medical records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily agreeing to the statements on this page I show that I have read this consent to treatment, have been told about the risks and benefits of treatments provided by Yinstill Reproductive Wellness, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and further conditions for which I seek treatment.