Authorization and Consent for Treatment
Acknowledgement of the Use of an Integrative Approach to Medical Care
This document is a binding contract setting forth the obligations I assume in consideration for the medical care and treatment to be provided to me. I as the patient agree to be bound by its terms.
FREE WILL: I am here of my own free will, representing no official agency or other organization, voluntarily requesting services for me and/or my dependents. I understand that all requests for information by official agencies or other organizations must be done in writing.
NOTICE IS HEREBY GIVEN THAT PERMISSION IS NOT GRANTED TO INDIVIDUALS WORKING IN AN OFFICIAL (E.G. GOVERNMENT) CAPACITY SEEKING INFORMATION WITHOUT THE WRITTEN CONSENT OF THE LEGAL COUNSEL REPRESENTING THE HEALTHCARE PROVIDERS AT HEALTHY KIDS PEDIATRICS.
INTRODUCTION: I have specifically sought out the services and perspective of the providers of Healthy Kids Pediatrics for their Integrative approach to medicine, drawing on Traditional and Complementary/Alternative Medicine methods. I have sought out my provider because I know that he/she is knowledgeable in both conventional and unconventional methods of treating illnesses and draws upon this experience and expertise to individualize and customize a treatment plan for each patient depending on the presentation. I understand that I will be presented with treatment options that include traditional and alternative approaches, and that ultimately, I will make the final decision on which method of treatment is right for me and my family.
RIGHT OF CHOICE: I have been fully informed that there are different schools of medical theory and that medicine is an evolving science. I am aware that in this evolving science, doctors sometimes differ on their approaches to diagnosis or treatment of illness or problems. I have had the opportunity to consider different approaches or schools of medical thought and ask questions of my provider. I understand that I have the right to accept or refuse medical care, based upon my personal judgment.
Complementary and Alternative Medicine, like any other treatment or medication, may or may not alleviate or cure the condition(s) for which it is offered. Likewise, I acknowledge that in any medical procedure or treatment that there are certain complications reported in medical journals and/or studies that are due to the procedure or treatment and unexpected adverse effects that may result. As part of the consideration I am giving to my provider in turn for treating me, I make a binding promise to notify the provider if I believe that I am suffering from any unexpected adverse effect. If I fail to notify my provider within a reasonable time of the onset of such unexpected adverse effect, I agree that any claim that I may have resulting from such adverse effect will be barred, waived and released. I further make a binding promise to notify the provider if I believe that I am suffering from any complication.
It is important that you read and understand the information contained in this form so that you can make an informed choice about being treated at Healthy Kids Pediatrics, by its agents, and your provider, specifically. If after reading this form, you have any concerns or questions regarding the care your child will receive, you should talk to your provider.
AUTHORIZATION: I have read the above or it has been explained to me. I acknowledge that I have been given the opportunity to ask my provider about any treatments which I am consenting to receive now and in the future including alternative forms of treatment, testing and the risks of such treatment, with the understanding that the ultimate decision lies with me regarding which treatment approach I desire.
Testing and/or treatments that may be offered or recommended by your provider at Healthy Kids Pediatrics may include, but are not limited to, Nutritional Support and/or testing, Allergy testing and control, Detoxification evaluation and support, Customized Vaccination Schedule, Vitamin supplementation, Elimination and Rotation diets for specific allergens, Comprehensive Stool Analysis, Saliva Cortisol Testing, General Laboratory Screening, Nebulizer Treatments, Vision and Hearing Assessment, Wart Removal
I acknowledge that the specific risks and complications of any treatment program requested will be discussed fully with my provider and I will have the opportunity to ask questions. I understand this is a general consent form to treat, accepting that the providers at Healthy Kids Pediatrics use alternative and traditional approaches to medicine.
I realize that I may leave Healthy Kids Pediatrics at any time. In doing so, I may be requested to sign a form acknowledging this decision. However, if I decide to revoke my consent to treatment, the consent shall remain applicable for any treatment and procedures rendered prior to any such revocation.
It was my independent choice whether to see a provider at Healthy Kids Pediatrics and it is always my choice whether to continue medical care with Healthy Kids Pediatrics. I also understand that the providers of Healthy Kids Pediatrics reserves the right, at any time and without cause, to discontinue any patient due to poor compliance with the recommended program or treatment plan for any other reason.
I have read this form that serves as an informed consent document and an authorization and have been given the opportunity to ask questions. If I have questions later, I understand I can contact a provider at healthy kids pediatrics. I will be given a signed copy of this document for my records. The risks and benefits to me have been explained and I am encouraged to and will have the chance to ask questions and these questions will be answered.
I, THE UNDERSIGNED, HAVE READ AND FULLY UNDERSTAND THE ABOVE INFORMATION, THE ELEMENTS OF MY INFORMED CONSENT, MY RIGHTS AND RESPONSIBILITIES, AND HEREBY GIVE CONSENT TO UNDERGO TREATMENT AT HEALTHY KIDS PEDIATRICS. INFORMATION ABOUT ME AND MY RECORDS WILL BE CONFIDENTIAL. DATA WILL BE STORED SECURELY AND WILL BE MADE AVAILABLE ONLY TO THE PERSONS PARTICIPATING IN MY EVALUATION AND SUBSEQUENT TREATMENT, IF ANY, UNLESS I SPECIFICALLY GIVE PERMISSION IN WRITING UNLESS OTHERWISE REQUIRED BY LAW.