Dr. Keila Roesner ND 1
Informed Consent
Informed Consent
Naturopathic doctors must obtain informed consent prior to beginning any treatment in order to
make sure that you are aware of any risks and/or side effects to treatments.
Dr. Keila Roesner ND uses the following treatment modalities in her practice: acupuncture,
botanical medicine, homeopathy, diet and nutritional counseling, lifestyle counseling, B12
injections and physical medicine.
Although Naturopathic Medicine is generally very safe and effective for most people, even the
gentlest of therapies may have certain complications in some physiological conditions such as in
pregnancy and lactation, in young children or in those taking multiple medications. Some therapies
must be used with caution in certain diseases including but not limited to diabetes/liver/kidney
disease. It is very important that you inform Dr. Keila Roesner ND immediately if any of the above
applies to you. Because each individual may respond differently to treatment, Dr. Keila Roesner ND
may not be able to anticipate and explain ALL risks and complications.
There are some risks to treatment with Naturopathic Medicine, including but not limited to
aggravation of pre-existing symptoms, allergic reactions to supplements or herbs,
pain/bruising/injury from acupuncture, fainting or injury to an organ with acupuncture needles
and bleeding from acupuncture needles. Dr. Keila Roesner ND will take precautions to minimize
these risks.
I understand that all information provided during my visit is strictly confidential. Information may
only be released upon my written request or as required by law.
I acknowledge that I have the opportunity to discuss with Dr. Keila Roesner ND the nature and
purpose of Naturopathic treatment in general and my treatment in particular.
I consent to the Naturopathic treatments offered or recommended to me by Dr. Keila Roesner ND. I
intend this consent to apply to all of my present and future naturopathic care.
Patient Name (print)
Patient Signature/Parent or Guardian Signature
Date
Stratford Health & Wellness Centre 137 Albert Street, Stratford ON, N5A 3K5 (519) 271-8323