Informed Consent for Treatment in Manchester, West Hartford, Stonington, Danbury CT

Step 1 of 3

Name of Patient*
First Last
Patient's Date of Birth*
MM slash DD slash YYYY
Patient Email*
I hereby request and consent to the performance of the following specific procedures on me (or on the patient named above for whom I am legally responsible) by the practitioners of Collaborative Natural Health Partners, LLC.
- Primary Care, Osteopathic medicine and functional medicine: providing the standard of care for primary medicine while offering natural alternatives when possible.
- Gynecology
- Common diagnostic procedures: e.g., physical exams, venipuncture, Pap Smears, laboratory
- Minor office procedures: e.g., dressing a wound, ear irrigation, suture removal, cryosurgery
- Medicinal use of nutrition: therapeutic nutrition, nutritional supplementation, nutritional consults
- Nutrigenomics: review of genetic information for nutritional purposes. The undersigned acknowledges that Collaborative Natural Health Partners, LLC does not employ any geneticists, and none of the employees of Collaborative Natural Health Partners, LLC should be considered substitutions for geneticists
- Botanical Medicine: botanical substances may be prescribed as teas, alcoholic tinctures, capsules, tablets, creams, plasters or suppositories
- Homeopathic remedies: the use of highly dilute quantities of naturally occurring plants, animals and minerals to gently stimulate the body’s healing responses
- Lifestyle Counseling and Hygiene: healthy lifestyle classes, diet therapy, promotion of wellness including recommendations for exercise, sleep, stress reduction and balancing of work and social activities
- Psychological Counseling
- Physical Medicine: osseous manipulation, soft tissue manipulation, electrotherapies, hydrotherapies, paraffin bath, intersegmental traction, cupping, acupuncture
- Acupuncture
- Nutritional Consultations
- Healthy Lifestyle Classes
- Other Procedures
List other procedures, if applicable
I understand that results are not guaranteed, and I recognize the potential risks and benefits of these procedures as described below:
General Potential risks: allergic reactions to prescribed herbs and supplements, side effects of natural medications, inconvenience of lifestyle changes, injury from venipuncture or procedures, fainting, aggravation of pre-existing symptoms, discomfort, pain, bruising, burns, lightheadedness.

Potential Risks of Acupuncture: bruising, numbness or tingling near the needling sites, dizziness or fainting, unusual risks include nerve damage, organ punctures, spontaneous miscarriage and infection.

Potential Risks of Cupping: bruising and scarring.

Potential Risks of Taking Herbs: nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives and tingling of the tongue.

I understand that Collaborative Natural Health Partners, LLC cannot anticipate and explain all risks and complications and I choose to rely on the practitioners of Collaborative Natural Health Partners, LLC to exercise their judgment during the course of the procedures which they believe at the time, based upon the facts they know, is in my best interests.

Potential benefits: restoration of health and the body’s 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 they are pregnant, as some of the therapies used could present a risk to pregnancy.

I understand that Collaborative Natural Health Partners, LLC will report to me only such information as a reasonably prudent person in my position would consider to be significant.

Alternatives: I understand that the naturopathic physicians are not primary care physicians and some of the procedures that I will receive at Collaborative Natural Health Partners, LLC are supplementary care to my primary physician or specialist. It has been recommended to me that I consult with a primary care physician and/or specialist to obtain information about conventional medicine treatment alternatives available to me.

With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by Collaborative Natural Health Partners, LLC or any of the personnel regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time.

I understand that Collaborative Natural Health Partners, LLC will keep a record 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 I may look at my medical record at any time and can request a copy of it by paying a fee as permitted under Connecticut law. I understand that my medical record will be kept for a minimum of seven (7), but not more than ten (10) years after the date of my last visit or as otherwise required by Connecticut law. I understand that any questions I have will be answered by the practitioners to the best of their ability.

I have read, or have had read to me, the above consent and have been given the opportunity to have all of my questions answered regarding Collaborative Natural Health Partners, LLC and the procedures to be performed. I acknowledge that I have received a copy of the Notice of Privacy Practice and consent to the use and disclosure of my protected health information for treatment, payment and healthcare operations.
Consent – Informed Consent*
I understand and agree to the above statements*

Financial Policy Disclosure

Examinations vary in price depending on the complexity and number of body systems that are examined. I understand that Collaborative Natural Health Partners, LLC bills my insurance company as a courtesy, and I further understand that I am responsible for any amount that my insurance company does not pay. If my balance is not paid in a timely fashion or based on a written and signed agreement, I promise to pay any and all collection, court and attorney fees related to the collection of my account. I understand that if my treatment is associated with a personal injury or accident claim, all medical bills will be paid at 100% of the fee schedule regardless of the outcome of my case. I understand that if a check or credit is returned for insufficient funds, I will be charged a $35.00 service charge.

Medical Records may be requested at the cost of $.65 per page plus postage.

Payments are due on the date of service unless other arrangements have been made. We accept cash, money orders, cashier’s checks, personal checks and credit card payments. A time of service discount is available for uninsured patients.

The Patient or Patient Representative:
MUST, at each office visit, inform Collaborative Natural Health Partners, LLC of the current address and telephone number of both the Patient and the Patient Representative.
MUST present all current insurance cards prior to each office visit
MUST verify, at each visit, the name of his/her family physician and all other demographic information.
MUST comply with the above payment policy requirements.

Should collection proceedings become necessary to collect balances on overdue accounts, The Patient will be terminated from the practice. Collaborative Natural Health Partners, LLC has the right to disclose to an outside collection agency all relevant personal and account information necessary to collect payment for services rendered. The Patient and the Patient Representative understand that they are responsible for all costs of collection including, but not limited to, all court costs, attorney’s fees.

Canceling appointments: Patients must give twenty-four (24) hours notice before canceling an appointment or they will be charged a $50.00 missed appointment fee. I have read and understand the above fees and policies and agree and understand that I am responsible or the cost of my care. I also agree and understand that I am responsible for payment of all deductibles and agree on payments related to my care.
Consent – Financial Policy Disclosure*
I understand and agree to the above statements*

Step 1 of 3

Financial Policy Disclosure

Insurance/Payment Waiver