Informed Consent Form

Informed Consent

Naturopathic Medicine is the treatment and prevention of disease by natural means.  Naturopathic Doctors assess the whole person, taking into consideration physical, mental and spiritual aspects of the individual.  Gentle, non-invasive techniques are generally used in order to stimulate the body’s inherent healing capacity.

A number of different approaches may be used throughout the course of treatment.  Naturopathic Doctors are trained in clinical nutrition, botanical medicine, homeopathy, Asian medical theory and acupuncture, hydrotherapy, lifestyle counseling, and physical medicine.

Even the gentlest therapies may cause complications under certain physiological conditions.  For this reason, it is very important that you inform your Naturopathic Doctor of any and all disease processes you are suffering from, as well as any medications (prescription and over-the-counter) that you are taking.  If you are pregnant, suspect you may be pregnant, or are breast-feeding, advise your Naturopathic Doctor immediately.

By signing your initials below, you understand that:

  • A record will be kept of the health services provided to you.  This record will be kept confidential and will not be released to others without your consent unless required by law.
  • The Naturopathic Doctor will answer your questions to the best of her ability.  Results are not guaranteed.
  • You are at liberty to seek or continue to seek medical care from other health care providers who are qualified to practice in Ontario.
  • Appointment fees, laboratory fees and supplements are to be paid for at the time of consultation.  A Missed Appointment Fee of $75 will be charged for any missed appointments or cancellations with less than 24 hours notice.  Naturopathic Medicine is not covered by OHIP.
  • You are free to withdraw your consent and to discontinue care at any time.

Informed Consent


I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others without my consent unless required by law.


I understand that the Naturopathic Doctor will answer my questions to the best of her ability. I understand that results are not guaranteed. I do not expect the doctor to be able to anticipate and explain all the risks and complications. With this knowledge, I voluntarily consent to diagnostic and therapeutic procedures mentioned above, except for (please list any exceptions):






I understand that fees and supplements are to be paid for at the time of consultation, and that a Missed Appointment Fee will be charged for any missed appointments or cancellations with less than 24 hours notice.


I have read and understand the above-stated policies and information. I intend this consent form to cover the entire course of treatment for my present condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time.






 

Contact

51 George Street
Waterloo, ON
N2J 1K8

Phone: 519-575-6016
Fax: 226-444-6755

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