1255 Sheppard Avenue East Toronto, ON M2K 1E2 416.498.1255 x 280 The Integrated Healthcare Centre at The Canadian College of Naturopathic Medicine Informed Consent & Request for Naturopathic Medicine Practitioner s Statement I would like to take this opportunity to welcome you to my practice. As a naturopathic doctor I use natural means to work with your body s innate ability to heal itself. As part of your naturopathic evaluation I will conduct a thorough case history, perform any necessary physical examinations, and take blood, urine, saliva, and/or stool samples when necessary. If your case requires, the physical may include more specific examinations such as breast, gynecological, rectal, prostate and/or genital exams. Naturopathic treatments may include but are not limited to: Dietary advice and therapeutic nutrition, including the therapeutic use of foods, nutritional supplements, intramuscular and intravenous injections; Botanical medicines and other natural health products may be given in the forms of teas, pills, tinctures (which contain alcohol), powders, suppositories, creams, or other forms; Homeopathic medicine which involves the use of highly dilute substances; Traditional Chinese medicine and acupuncture which involves the insertion of sterilized, disposable, stainless steel needles, through the skin into underlying tissues at specific points on the body; Hydrotherapy, the use of water as a healing medium; Lifestyle counseling; Over the counter medications. Patient/Guardian Initial
Patient s Statement of Consent The treatment and therapies rendered or recommended by Daniel Lander may be different from, but are not mutually exclusive of those offered by a medical doctor or other licensed health care provider. As such I am at liberty to seek or continue to receive medical care from a physician, or other health care provider qualified to practice in the province of Ontario. Although naturopathic medicine primarily uses natural therapies and minimally invasive therapies, there are some rare health risks that can arise. These include but are not limited to: Aggravation of pre-existing symptoms; Adverse reactions to supplements or herbs; Pain, discomfort, bruising, or injury from venipuncture (blood draw for lab purposes), acupuncture, or parenteral (IV) therapy; Muscle strains or disc injuries from spinal manipulation; I acknowledge that no guarantees have been given to me concerning the results intended from the treatment. I further confirm that I am free to withdraw my consent and to discontinue naturopathic treatment at anytime. I acknowledge that I have discussed or have had the opportunity to discuss with Daniel Lander, the nature and purpose of naturopathic medicine in general and my naturopathic treatment in particular as well as the consents in this form. I give my informed consent to Daniel Lander to provide me with naturopathic medical consultation, assessment and/or treatment. I recognize that this consent covers the entire course of treatment for my present condition as well as any future conditions for which I seek treatment. [For women] I agree to alert Daniel Lander if I know or suspect that I am pregnant, or if I plan to become pregnant, as some of the therapies could present a risk to the pregnancy.
Notice of Privacy Practices 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 the law requires it or if I give my written consent. I realize that in rare instances courts may subpoena my medical records, which means that my records will be required to be released. My case may also be discussed for educational purposes and information from my medical record may be analyzed for research purposes in which my identity will be kept confidential. In addition, Daniel Lander is required to report me to the appropriate authorities in the following instances: When I am in imminent danger of harming myself or others; When there is reasonable suspicion that I am neglecting and/or emotionally, physically, or sexually abusing a minor; If I engage in sexual relations with any of my healthcare providers. I may access my medical records at any time and can request a copy by paying the appropriate fee. I authorize Daniel Lander to release any and all medical information/records for the following reasons: insurance, telephone consultations with my other healthcare providers, transfer of medical records to my other health care providers for continuance of care. By signing below, I acknowledge that I have received, read, and accepted a copy of the notice of privacy practices.
Financial Policy/Patient Contract By signing below, I acknowledge: I have reviewed the fee schedule and will provide payment for all visits and labs at the time of service. If I have third party insurance or an extended health plan that covers naturopathic medical care, I agree to make claims to my insurance directly. Daniel Lander will provide a comprehensive summary of services. OHIP does not currently cover naturopathic medical care. I will be charged for missed appointments unless 48 hours notice is given. There is $30.00 charged for returned cheques. If I am having any difficulty with my treatment plan or in the event that any adverse reactions occur, I will contact the clinic immediately.