Naturopathic Medicine Treatment Consent Form

(Filled by the patient or guardian)

First Name: _________________________ Last Name: ___________________________________

Home Address: _________________________________________________ Tel:

____________________ Date of Birth: _____________ Age: _______ Occupation:
_________________________________

Email Address: ____________________________

Naturopathic Medicine is a form of natural medicine.

1. I take sole responsibility for my consent to follow the advice and treatment suggested
by Dr______________
2. I authorize Dr.________________ to perform the following procedure(s) and treatment:
-Naturopathy, Homeopathy, Acupuncture, Hydrotherapy, Nutritional Counseling,
Detoxification, Herbs, Physical and Lifestyle counseling or any other natural treatment
that he considers advisable in his opinion, judgement and conclusion.
3. The nature and purpose of the treatment, possible methods of treatment, alternate
methods of treatment, the risks involved and the complications will be fully explained to
me by the above named doctor and or their associates and or assistants.
4. It is my responsibility to comply with the therapies recommended.
5. I acknowledge that no guarantee or assurance has been made to me as to the results
that may be obtained
6. I understand that when my regular Naturopath is unable to attend to me, my care may
be administered by an associate Doctor of Naturopathy, without another consent being
prepared.
Note: medical records will not be released without your written consent
No refunds on services rendered and remedies supplied.
I certify that I have read and fully understood the above consent to treatment and that this
form was completed prior to treatment and signed by me without duress.
Signature of Patient: __________Date: ________
Signature of Witness _______ Date: _________
Note: when the patient is a minor or otherwise incompetent to give consent, the consent of a
parent or guardian must be obtained.
Signature of Parent or Guardian: ______________________
Name of Signatory: ________________________ Date _________________