I, as a patient, have the right to be informed about my condition and recommended care. This disclosure is to help me become better informed so that I may make the decision to give, or withhold my consent as to whether or not to undergo care, having had the opportunity to discuss the potential benefits, risks, and hazards involved.
I hereby request and consent (for myself or for the patient for whom I am legally responsible) to examination and treatment by all practitioners working and training at North Seattle Natural Medicine.
I understand that I have the right to ask questions and discuss to my satisfaction with my North Seattle Natural Medicine practitioner:
1) My suspected diagnosis or condition;
2) The nature, purpose and potential benefits of the proposed care; 3) The inherent risks, complications, potential hazards, or side effects of treatments and procedures;
4) The probability or likelihood of success;
5) Reasonable available alternatives to the proposed treatments or procedures;
6) The possible consequences if treatment or advice is not followed and/or nothing is done.
I understand that my treatment and evaluation may include, but is not limited to:
● Physical exam (general, musculoskeletal, orthopedic, and neurological assessments);
● Common diagnostic procedures (venipuncture, pap smears, diagnostic imaging, laboratory evaluation of the blood, urine, stool, and saliva);
● Soft tissue and osseous manipulation (massage, neuromuscular technique, muscle energy stretching, cranio-sacral therapy, osseous manipulation of the extremities and spine);
● Allergy skin testing and immunotherapy;
● Electromagnetic and thermal therapies (ultrasound, low and high volt electrical muscle stimulation), transcutaneous electrode stimulation, and infrared or ultraviolet therapies);
● Dietary advice and therapeutic nutrition (use of foods, diets, supplements, and intramuscular injections);
● Herbs/Natural medicines (various therapeutic substances including plants, mineral and animal materials. Substances may be prescribed in the forms of teas, creams, pills, powders, tinctures, suppositories, topical creams, pastes, plasters, washes, and other vehicles which may contain alcohol or allergens which it is the patient’s responsibility to monitor);
● Homeopathic remedies (often highly-diluted quantities of natural substances);
● Hydrotherapy (use of hot or cold water, colon hydrotherapy, cryotherapy);
● Over the counter and prescription medications (including only FDA-approved medications).
● Acupuncture techniques (needling of soft tissues at specific acupuncture points, electro-acupuncture, cupping, moxibustion and gua-sha).
● Injection therapies (including injection of various natural substances such as but not limited to: B vitamins or combination of other nutrients injected intramuscularly or intravenously, Hormone Pellet Therapy, Prolotherapy injections utilizing inert sugars, or other therapeutic injections including platelet rich plasma).
I understand and I am informed that in the practice of naturopathic medicine, there are some risks and benefits involved in evaluation and treatment, including but not limited to: Pain; discomfort; blistering; minor bruising; discoloration; infections; burns; loss of needle insertions; allergic reaction to prescribed substances; soft tissue or bone injury; an aggravation of pre-existing symptoms; and emotional response.
Notice to pregnant patients: All patients must alert the provider if they know or suspect that they are pregnant, since some common naturopathic treatments can present a risk to pregnancy. Treatment intended to induce labor requires a letter from a primary care provider providing authorization and recommending such a treatment.
Notice to patients with bleeding disorders, pacemakers, and cancer: For your safety, it is important to alert your provider of these conditions.
I do not expect North Seattle Natural Medicine’s practitioners to be able to anticipate and/or explain all risks and complications involved in my treatment. I wish to rely on the provider to exercise best judgement during the course of my evaluation and treatment based on the known facts. I understand that it is my responsibility to request that the provider explain therapies and procedures to my satisfaction. I further acknowledge that no guarantees have been made to me concerning the results of my treatment. By signing below, I acknowledge that I have been provided ample opportunity to read this form or that it has been read to me. I understand the above and have given my consent to evaluation and treatment by North Seattle Natural Medicine’s practitioners. I intend for this to act as a consent for my entire course of treatment for both my present condition and any future conditions that may arise.