Informed Consent s5

INFORMED CONSENT

Naturopathic Medicine is the treatment and prevention of diseases by natural means. Naturopathic Doctors assess the whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. Gentle, non-invasive techniques are generally used in order to stimulate the body’s inherent healing capacity. Dr. Tanya Manikkam N.D. will take a thorough history and perform a physical exam. If your case requires, the physical examination may include a breast, rectal, prostate or genital exam.

The following modalities may be used in treatment: Nutritional Counseling, Botanical Medicine, Homeopathy, Physical Medicine, Hydrotherapy and Lifestyle Counseling.

It is very important that you inform Dr. Tanya Manikkam N.D. immediately of any of the following:

• Allergies • • Current illnesses • Presence of pacemaker or other implants • Current use of medication/drug • Pregnancy • Breastfeeding • 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 consequence of not having the diagnosis and/or treatment acted upon.

• There are slight health risks associated with treatment by naturopathic medicine. These include but are not limited to: • Homeopathic remedies may occasionally result in aggravation of pre-existing symptoms. • Some patients experience allergic reactions to certain supplements and herbs. • Pain, bruising or injury from venipuncture • Muscle strains and sprains or disc injuries from spinal manipulation. • There is a very small potential for stroke in neck manipulation.

• I understand that Dr. Tanya Manikkam N.D does not guarantee treatment results. The nature of any treatment provided will be explained to me and any questions I may have will be answered. I intend for this consent form to cover my entire course of treatment with Dr. Tanya Manikkam N.D. and I am free to withdraw my consent and to discontinue treatment at any time. • I understand that it is my full responsibility to be aware of the details of my coverage regarding any Extended Health Care Plan and do not hold Dr. Tanya Manikkam N.D. liable for any misinterpretation regarding reimbursement of paid services between myself and my healthcare insurance company.

• I hereby consent to receive naturopathic treatment and understand the possible risks outlined above.

• Patient Name (please print): ______• Signature of Patient or Parent/Guardian: ______Date: ______

• Signature of Naturopathic Doctor: ______