6480 Weathers Place, Ste 106, San Diego, Ca 92121 Phone: 858-455-9726, Fax: 858 455 9159
I hereby give my consent for medical care. I understand that Kamyar M. Hedayat, MD is a medical doctor who practices a form of holistic medicine called endobiogeny, which is based on modern principles of medicine, but is holistic. By consenting to treatment, I acknowledge that I prefer a natural approach to my medical care, and that is why I am seeking the assistance of Dr. Hedayat today. Alternatives to undergoing an endobiogenic treatment include standard medical treatments including the use of pharmaceutical agents, invasive evaluation and surgical procedures. Dr. Hedayat may offer a standard treatment or may offer a natural approach or a combination thereof for the treatment of my condition. The endobiogenic approach to treatment includes the use of various natural treatments, which while based in scientific research and found to be effective and considered to be safe to use, are not considered the standard for medical treatment, and are not FDA approved for the treatment of my condition.
Some of the benefits of using natural treatments include, but are not limited to improvement of my condition and related symptoms, a reduction in side effects related to current standard medical treatment, and/or avoidance optional invasive procedures. Some of the risks of exclusively using natural treatments include, but are not limited to worsening of my condition and related symptoms, including possibly death, the need for the use of medication or surgical intervention at a later date.
Other physicians and healthcare personnel may from time to time participate in or observe my care. I extend this authorization to these other physicians and healthcare personnel. Although unlikely, in the event that my physician is not available to perform the above treatment or procedure, I understand that this authorization may be extended to them. If possible, I will be notified of the substitution. I also understand that, during the treatment plan or procedure, it may be necessary to administer other medical treatment. While I authorize necessary medical care, I limit that consent, however, to what is indeed medically necessary.
Dr. Hedayat gave me an opportunity to ask questions and seek further information regarding the above items. I believe that I do not require further information at this time, and am prepared to proceed with the recommended treatment or procedure. I believe that my physician has honored my right to make my own informed healthcare decision, give my consent voluntarily and freely, and certify that I can give consent (that is, I am not a minor or incompetent to make my own healthcare decisions).
I understand that I can revoke this consent at any time up until the time that the treatment or procedure has started.
Patient’s Printed Name
Signature of Patient
Time Date