Naturopathic Informed Consent Form
Privacy of your personal information is an important part of Hart & Sol Integrative Healthcare. We understand the importance of protecting your personal information. We are committed to collecting, using, and disclosing your personal information responsibly. We will try to be as open and transparent as possible about the way we handle your personal information.
All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are trained in the appropriate use and protection of your information.
We ensure that:
The clinic will collect, use, and disclose information about you for the following purposes:
Naturopathic medicine is the treatment and prevention of diseases by natural means. Your naturopathic doctor (ND) will take a thorough case history, and when medically appropriate/necessary, they will perform a physical examination and order laboratory tests. If your case requires it, 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.
The staff is trained to handle emergencies should the need arise. There are slight health risks associated with treatment by naturopathic medicine. These include but are not limited to:
I understand:
All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are trained in the appropriate use and protection of your information.
We ensure that:
- Only necessary information is collected about you
- We only share your information with your consent
- Storage, retention, and destruction of your personal information complies with existing legislation and privacy protection protocols
- Our privacy protocols comply with privacy legislation and standards of our regulatory body, the College of Naturopaths of Ontario
The clinic will collect, use, and disclose information about you for the following purposes:
- To assess your health concerns
- To provide health care
- To advise you of treatment options
- To establish and maintain contact with you
- To send you newsletters and other information mailings
- To remind you of upcoming appointments
- To communicate with other treating health-care providers
- To allow us to efficiently follow-up for treatment, care, and billing
- To complete claims for insurance purposes
- To invoice for goods and services
- To process credit card payments
- To collect unpaid accounts
- To comply with all regulatory and legal requirements including court orders, statutory requirements to advise authorities of child abuse, and reporting diseases and individuals who may be an imminent threat to harm themselves or others
Naturopathic medicine is the treatment and prevention of diseases by natural means. Your naturopathic doctor (ND) will take a thorough case history, and when medically appropriate/necessary, they will perform a physical examination and order laboratory tests. If your case requires it, 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.
The staff is trained to handle emergencies should the need arise. There are slight health risks associated with treatment by naturopathic medicine. These include but are not limited to:
- Homeopathic remedies may occasionally result in the aggravation of pre-existing symptoms. When this occurs the duration is usually short.
- Some patients experience allergic reactions to certain supplements and herbs. Please advise your ND of any allergies you may have.
- Pain, bruising, or injury from venipuncture or acupuncture or parenteral therapy.
- Fainting.
- Puncturing of an organ with acupuncture needles (a very rare occurrence).
- Accidental burning of the skin from the use of moxa.
- Muscle strains and sprains or disc injuries from spinal manipulation.
- There is a very small potential for stroke in neck manipulation. Patients are thoroughly screened by the ND prior to manipulating the neck as it may not be appropriate in some medical conditions.
I understand:
- The clinic does not guarantee treatment results.
- That my ND will explain to me the exact nature of any treatment provided and will answer any questions I may have.
- That I am free to withdraw my consent and to discontinue treatment at any time.
- That to avoid being charged a cancellation fee, I will provide the clinic with at least 24 hours notice before my scheduled appointment if I need to cancel or reschedule. I understand that the cancellation fee will be half the fee for the service I would have received and will not be billable to my insurance company.