I hereby request and consent to the performance of naturopathic procedures (including examination, diagnostic testing, and the use of natural substances such as vitamins, minerals, botanical medicines, bioidentical hormones, and prescription drugs) on me (or on the patient named below, for whom I am legally responsible) by Dr. Seligman; a licensed Naturopath.
I understand and am informed that, as in the practice of medicine and naturopathic medicine, there are some risks to the exam and treatment including, but not limited to Naturopathic Medicine- drug side effects, nutrient-drug interaction, and herb-drug interactions. I understand and am informed that results from treatments may vary and are not guaranteed. In addition, I understand that my compliance with diet recommendations, supplements, prescribed medications, prescribed exercises, and lifestyle modification will increase the effectiveness of my care and enhance or maintain the results. I understand a referral to another physician or specialist may be necessary due to the nature of my condition and limitations in the scope of practice of Naturopathic Medicine.
I am aware that Naturopathic Physicians are considered primary care providers in the state of Washington. I acknowledge that the scope of practice of a Naturopathic physician has limitations including limited prescription privileges and lack of hospital privileges. Consequently, a referral to a specialist or emergency room may be deemed necessary under certain circumstances and in my best interest.
I do not expect the doctor to be able to anticipate and explain all the risks and complications, and I wish to rely on the doctor to be able to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts known.
I have read, or have had read to me the above consent. I have also had an opportunity to ask
questions about its content, and by initialing below I agree to the above-named procedures. I intend this consent
form to cover the entire course of treatment for my present condition and for any future condition(s) for which I