Informed Consent to Naturopathic Treatment
Naturopathic doctors are health care practitioners who specialize in natural medicine. Naturopathic medicine focuses
on whole-person wellness. The medicine is tailored to the client and emphasizes prevention and self-care.
Naturopathic doctors work with all other branches of medical science, referring clients to medical doctors, specialists,
and other practitioners when appropriate.
I, _______________, understand that Dr. Julie Neal, ND and/or Dr. Rachelle Price, ND will answer any questions to
the best of their abilities. As with any therapeutic regiment, I understand that the likelihood of physical change is
dependent on adherence to my individualized plan.
I, _______________, hereby authorize Boulder Natural Health to provide the following naturopathic care as necessary
to facilitate my health care:
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Medicinal use of nutrition: therapeutic nutrition, nutritional
supplementation.
Botanical medicine: botanical substances may be
recommended as teas, alcoholic tinctures, capsules, tablets,
crèmes, plasters, or suppositories.
Homeopathic medicine: the use of highly dilute quantities of
naturally occurring plants, animals, and minerals to gently
stimulate the body’s healing responses.
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Lifestyle and hygiene counseling: diet therapy,
promotion of wellness including recommendations
for exercise, sleep, stress reduction and balancing of
work and social activities.
Crainosacral therapy and hydrotherapy.
Laboratory assessment if indicated.
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The doctors at Boulder Natural Health do not provide primary care medicine. We provide naturopathic wellness care to
support our clients’ optimal wellbeing. Naturopathic doctors provide wellness consultations, including diet, lifestyle
and nutritional counseling, as well as recommendations for homeopathic, vitamin and nutrient, or herbal supplements.
I recognize the potential risks and benefits or Naturopathic care as described below:
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Potential risks: allergic reactions to recommended herbs, supplements, side effects of natural medicine, inconvenience of
lifestyle changes, emotional release, emotional distress, healing crisis.
Potential benefits: restoration of health and body’s maximal functional capacity and optimal wellness, relief of pain and
symptoms of disease, and prevention of illness or its progression.
Notice to pregnant women: All female clients must alert the doctor if they know or suspect that they are pregnant. Some
of the therapies used could present a risk to the pregnancy.
The doctors at BNH do not provide any acute or urgent care. We do not carry pagers. If you have any acute or lifethreatening emergency you must call 911, go to the ER, or other urgent care facility. Naturopathic doctors do not
prescribe any prescription medications. Any questions concerning your prescription medications must be directed to
the original prescriber or another medical doctor. I understand that I am expected to have a local primary care
physician in addition to the naturopathic care that I will receive from Boulder Natural Health.
With this knowledge, I voluntarily consent to the above naturopathic care, realizing that no guarantees have been given
to me by Boulder Natural Health 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.
By signing this consent form, I, ___________________(print name) understand that naturopathic doctors are not
licensed in the state of Colorado and that Dr. Julie Neal, ND, is licensed in the state of Washington and Dr. Rachelle
Price, ND is licensed in the state of Oregon. I also understand that Dr. Neal and Dr. Price have passed examination
boards required for a naturopathic license. (Initial) ___________
A record will be kept of health services provided to you. This record is confidential and will not be released to anyone
without your written consent or legal documentation.
Client Signature:_______________________________________________________________ Date:_________
Client Name: (please print) _______________________________________________________
Guardian Signature: (if patient is under 18 years old) ___________________________________
Guardian Name: (please print) _____________________________________________________
Boulder Natural Health | 777 29th St. Suite 401, Boulder, CO 80303 | ph: 303-960-3920
www.bouldernaturalhealth.com