CONSENT FOR TREATMENT, FINANCIAL POLICY &
ACKNOWLEDGEMENTS
AUTHORIZATION OF TREATMENT:
I, _________________________________________________, hereby authorize medical treatment of myself or my minor child by Malinda Horton, NP. I understand that services provided by Malinda Horton, NP are of a consultative nature and not intended to replace services provided by my primary care healthcare provider. This also means that she is not taking primary responsibility for managing my health condition, but is complementing the care I receive from my primary care physician. I understand that in addition to a primary care physician, it may be in my best interest to have appropriate specialists, such as a cardiologist if I have cardiac problems or a pediatrician if I am seeking treatment for my children. I also understand that it is my responsibility to inform Malinda Horton, NP of the name and contact information for my primary care physician, specialists and diagnoses I have received, and of any treatments I have had or am now undergoing for current conditions.
I also understand that it is important for me to let my primary care physician know about any
Recommendations or treatments performed by Malinda Horton, NP in order to ensure that my care is properly coordinated. I understand that care I receive from Malinda Horton, NP may be considered non-conventional and is commonly referred to as complementary, alternative, holistic or integrative medicine. This type of care can include a variety of innovative medical treatments as well as acupuncture, nutritional and herbal consultation, clinical aromatherapy, manual medicine and mind-body approaches. Many of these services may not be recognized as standard medical practice, generally accepted by the medical community, or approved by the
Food and Drug Administration or other regulatory agencies. I understand that these therapies may not be approved for reimbursement by my insurance company. I am seeking care from
Malinda Horton, NP in order to benefit from her special training in Integrative Medicine and receive advice and treatment utilizing complementary therapies.
I understand that even though she may address issues affecting my general health, the practice is focused on a complementary approach to medicine. I understand that Malinda Horton, NP does not provide emergency or on-call assistance.

Cornerstone Integrative Healthcare, Inc.
Malinda Horton, NP
The following are possible therapies which may be recommended:
Nutritional therapy: Consultations may include discussion of dietary advice and use of dietary supplements. I may be advised to assume an elimination or detoxification diet in order to identify food sensitivities or improve intestinal health. While these diets are generally safe, some people may experience an increase in symptoms or develop flu-like symptoms as the body cleanses itself from toxins. These symptoms may include mild fever, loss of energy or appetite, rash and irritability.
Herbal supplements: While herbs and botanical products are generally available over-thecounter and considered safe based upon their long history of use, many of them have not been studied. There is some risk that these products could prove harmful, particularly if I am allergic to them, which in rare circumstances could lead to serious consequences. I understand that interactions between herbs, and between herbs and drugs, are not fully known. While unlikely,
I could have an adverse reaction or experience a reduction or increase in the effect of other medications. This can have serious consequences for some medications, such as for high blood pressure or blood sugar. I agree to inform Malinda Horton, NP of all medications, dietary and herbal supplements that I am currently taking and to inform her of any adverse reactions I experience while taking dietary or herbal supplements. I agree to seek emergency care if the reactions are of a serious nature before consulting with Malinda Horton, NP.
Clinical Aromatherapy: Clinical Aromatherapy is the use of essential oils intended to achieve a therapeutic effect. Recommendations may include the use of essential oils through inhalation or topical application. I understand that occasionally adverse reactions to essential oils can occur including skin reactions. I agree to inform Malinda Horton, NP if I have an allergy, skin condition or any other medical condition which would be a contraindication to the use of essential oils.
Manual Medicine: Includes acupressure, massage, frequency specific microcurrent therapy
(FSM). FSM is a technique utilizing microcurrents which are directed through the body via an
FDA approved machine which may improve conditions including, but not limited to chronic muscular pain, headache, scar reduction, myofascial release and skin rejuvenation. I understand that I will sign a separate consent form for FSM treatment if I choose to pursue this.
Mind/Body Medicine: Mind/body medicine is the use of techniques to connect the mind and body to improve patient well-being through the use of such techniques as meditation, prayer, biofeedback, massage, Yoga and lifestyle changes. These techniques may help with stress reduction and improved emotional health which may have an effect on my physical health.
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Cornerstone Integrative Healthcare, Inc.
Malinda Horton, NP
Medical Records Release Authorization: I authorize Malinda Horton, NP to release my medical information to any physician or health practitioner to whom I am being referred for care and to any payer of my care including my insurance carrier or managed care program upon their specific request. I also authorize release of my medical records from any healthcare provider to
Malinda Horton, NP. Such authorization is effective of a period of one year, and extends to records regarding my minor child, if applicable.
Privacy Statement: While Malinda Horton, NP and Cornerstone Integrative Healthcare, Inc. is not required to follow the privacy requirements under the Health Insurance Portability and
Accountability Act (HIPAA), she does respect your privacy and will only release information to further your treatment when referring you to another practitioner, assist you in obtaining payment, managing her own internal operations, or as specifically authorized by you.
PATIENT/GUARDIAN ACKNOWLEDGEMENT: I certify that the information I provide to my practitioner and my insurance company is correct. I certify that I am here to receive medical care and for no other purpose. I do not represent any third party. I have read, understood and agree to the foregoing. I understand that Malinda Horton, NP does not make any representations, claims or guarantees that I will be helped with my medical problems or conditions by undergoing treatment received from Malinda Horton, NP but that she will make every reasonable effort to help me achieve my healthcare goals. I understand that I have the right to review this consent with a lawyer if I choose before accepting any medical services from
Malinda Horton, NP. I have executed this consent freely and willingly understand its provisions.
I recognize that Malinda Horton, NP will rely upon my signing of this document in accepting me or my minor child as a patient. The authorizations may be revoked by me in writing at any time.
Such revocation will not affect my financial responsibility to pay for services rendered. I acknowledge receipt of a copy of this consent if I have requested it.
Patient’s name: ____________________________________________________
Responsible party signature:__________________________________________
Relationship to patient:______________________________________________
Date: _______________
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