Patient Information Consent Form For Chinese Medicine (Page 2 of 2) in pdf

Patient Information & Consent Form for Naturopathic Medical Care

Naturopathic Medicine is a system of health care that treats and prevents disease by using natural and non-invasive

therapies such as clinical nutrition, herbal medicine, homeopathy, physical medicine, lifestyle counseling and

hydrotherapy. It is based on the belief that the human body has an innate healing ability. Your naturopathic visit will

most likely consist of a thorough case history and physical exam. Lab tests and more specific examinations may be

necessary and performed by your ND or referred to your MD or a specialist. An ND may also prescribe an over-the-

counter medication or pharmaceutical drug when deemed appropriate.

Statement of Acknowledgment

I understand that the form of medical care I will receive is based on naturopathic principles and practices. I will inform

my ND of any health concerns, allergies, medications, supplements and medical interventions. I will notify my ND if I

have any bleeding disorders, pace makers or cancer. I will also inform my ND if I am pregnant and/or breastfeeding.

I understand that although naturopathic treatments are generally safe and gentle, there may be health risks associated

with some treatments, including but not limited to:

~ allergic reactions to a supplement or herb

~ pain, soreness or bruising from bodywork, physical medicine, injections or venipuncture

~ aggravation of pre-existing symptoms (which may be part of the healing process)

~ new symptoms or the return of old symptoms (which may be part of the detoxification process)

I also understand that:

~ treatment results are not guaranteed

~ my ND will not be able to anticipate and explain all the risks and complications of all treatments and procedures

although she will do so as thoroughly as possible to the best of her ability and will exercise judgment based on the

facts at hand during the course of any diagnostic procedures and/or treatment plans which she feels at the time are in

my best interest

~ I am always free to discontinue care and/or seek care from another qualified health practitioner

I have read over and understand the following Email/Phone Policy:

Email/Phone Policy: Please keep in mind that communications via email are not secure. Also please keep in mind that we

cannot formally diagnose your condition from information via email and communications via email cannot replace the relationship

you have with your healthcare practitioner.

There is no charge for emails or phone calls regarding clarification of your current treatment plan such as supplement or medication

doses, or when your physician has requested that you check in about your response to a treatment. There will be a fee, however, of

$35 to $78, depending on length of time required, for emails or phone calls regarding a new health problem, information

requiring medical advice or an issue that requires your chart being pulled and information being recorded. You are always

welcome to schedule an appointment or hold your questions until your next session if it’s not an urgent matter.

Thank you for your patience and your understanding of our policy. Please note: insurance does not cover this expense and this fee

will be your responsibility. Also please note that your practitioner may call or email a response saying that it is easier to discuss your

questions during an office visit or that she will answer your questions in person during your next session.

We will do our best to answer your questions via email or phone within 3 business days. If you have an urgent health

problem that needs to be addressed, please go to urgent care or the hospital. In an effort to respond in a timely manner,

responses may be brief and direct. Should you need more detailed description or explanation, please schedule an appointment.

Feel free to ask if you need any clarification about this policy.

Statement of Consent

I have carefully read and understand all of the above information.

I understand that I may ask my ND for a more detailed explanation.

I understand that regular primary care by a licensed physician is strongly recommended.

I consent to treatment while under the care of Dr. Vanda Huang and understand that I am free to refuse/stop treatment

and/or seek alternative treatment at any time. I will communicate any concerns or questions.

Printed Name: _________________________________________________

Signature:_____________________________________Date:____________

Patient Information Consent Form For Chinese Medicine Page 2

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