Consent For Treatment
INFORMED CONTENT OF TREATMENT
I hereby authorize LIVV Natural Health to perform the following specific procedures as necessary to facilitate my diagnosis and treatment:
Medicinal use of nutrition: Therapeutic nutrition, nutritional supplementation, and intravenous and intramuscular vitamin injections
Bioidentical Hormone Therapy: The use of compounded bioidentical hormones to help restore and balance optimal hormone levels.
Botanical medicine: Botanical substances may be prescribed as teas, alcohol or glycerite based tinctures, capsules, tablets, creams, plasters, or suppositories.
Homeopathic medicine: The use of highly dilute quantities of naturally occurring plants, animals, and minerals to gently stimulate the body’s healing response.
Lifestyle counseling: Recommendations for diet, exercise, sleep, stress reduction, and balancing of work and social activities.
Physical medicine: Hydrotherapy, stretching, manipulation, and electrical muscle stimulation.
I recognize the potential risks and benefits of these procedures as described below:
Potential risks: allergic reactions to prescribed herbs and supplements, side effects of natural medications, aggravation of pre-existing symptoms, discomfort, pain, infection, burns, nausea, lightheadedness, inconvenience of lifestyle changes, injury from injections, venipuncture, or procedures. Notify LIVV if you experience any symptoms that may be secondary to the above procedures or if there is any change in your medical history, prescriptions, supplements, and other treatments.
Potential benefits: restoration of health and the body’s maximal functional capacity, relief of pain, and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or its progression.
Notice to pregnant women: All female patients must alert the doctor if they know or suspect that they are pregnant as some of the therapies used could present a risk to the pregnancy.
Notice to Women receiving hormone therapy: All females receiving hormone therapy must agree to follow protocol set by the doctor, run blood work every 3 months, see a gynecologist and receive yearly PAP and breast exams. I understand that if I do not follow protocol set by the doctor, they have the right to refuse refills and/or future care
Notice to Men receiving hormone therapy: All males receiving hormone therapy must agree to follow protocol set by the doctor, run blood work every 3 months, and have established care with a urologist. I understand that if I do not follow protocol set by the doctor, they have the right to refuse refills and/or future care.
With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by my practitioner regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and to discontinue participation in the
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 unless so directed by myself, or my representative, or unless it is required by law.
I understand that my medical record will be kept for a minimum of three, but no more than ten years after the date of my last visit. I
understand that information from my medical record may be analyzed for research purposes, and that my identity will be protected and kept confidential.
I understand that any questions I have will be answered by my practitioner to the best of his/her ability.
I HAVE READ, UNDERSTAND, AND HAD ALL MY QUESTIONS ANSWERED ABOUT THIS PROCEDURE AND ITS RISKS AND BENEFITS TO ME.
