D'Adamo Institute for the Advancement of Natural Therapies
Informed Consent and Request for Treatment
Naturopathic and Chiropractic Medicine are unique and distinct systems of health care that emphasize the
use of preventive and natural therapeutics. The Naturopathic Doctors (ND's) and Chiropractic Doctors (DC's)
of the D'Adamo Institute for the Advancement of Natural Therapies (“D’Adamo Institute”), hereafter referred to
as the “doctors,” are trained in the prevention, diagnosis, management and treatment of both acute and
chronic health conditions.
As a patient, I have the right and responsibility to be informed about my health care and the proposed course
of treatment. I have the right to ask questions and discuss, to my satisfaction, my suspected diagnosis and
nature of the proposed care and treatment. I have the right to ask questions and discuss to my satisfaction
the risks, complications, hazards, possible side-effects, available alternative treatments, as well as,
the benefits of the proposed course of treatment or procedure, and the consequences if the proposed course
of treatment is not followed.
I understand that evaluation and treatment by the doctor(s) may include, but is not limited to the following
treatment modalities: Naturopathic Medicine, Clinical Nutrition, Botanical Medicine, Homeopathic
Medicine, Hydrotherapy, Physical Medicine, and/or Lifestyle Counseling. These treatment modalities are
achieved through physical examination, common diagnostic procedures, laboratory evaluations, tissue
and muscle manipulations, electromagnetic and thermal therapies, herbs and natural remedies, dietary
and nutritional advice, homeopathic remedies, hydrotherapy, counseling and recommendations for over
the counter medications.
I understand that some doctors at the D’Adamo Institute also practice traditional Chinese and Asian
medicine. That form of evaluation and treatment may include, but is not limited to: acupuncture, electrical
and magnetic devices, cupping, Gua Na (rubbing on an area of the body with an instrument) Chinese
massage, dietary advice, herbs and other natural remedies, point injection therapy, infrared, sonopuncture and laser-puncture.
As in all forms of health care and medicine there are risks and benefits in the evaluation and treatment of
a patient. I know that it is my responsibility to ask those questions that I feel I need answers to, and I am
satisfied my doctor has addressed all of my questions and the potential risks and benefits to other
treatment modalities and explained those to me. I do not expect my doctor to explain all of the risks and
complications, and I rely on his/her judgment during the course of any procedure. I also know that if I
know or suspect that I am pregnant or have a bleeding disorder, a pacemaker or cancer, I must alert my
provider. No guarantees have been made to me concerning the results of the proposed treatments that I
am to receive.
I have been provided ample opportunity to read this document, or it has been read to me, and I hereby
give my consent to the evaluation and treatment. Further, I consent to the ongoing evaluation and
treatment for my diagnosis and condition from this day forward. I am agreeable to signing a separate
consent form for each office appointment or treatment, but that is not necessary.
In all forms of medical treatment, there are certain risks and benefits applicable to each. I have reviewed
the following list of treatments offered at D’Adamo Institute and the risks associated with all of these
treatments. Additionally, my doctor has further explained the specific risks and contraindications for the
specific treatments that I am to receive, as well as alternatives to treatment, including the option of having
no treatment.
The available therapies include:
Far Infrared Sauna, Laser Therapy, G5, Tens Cam, Inhalation, Ginger Packs Adrenals, Hot Pack, HCG,
Colon Irrigation, IV’s, RE-5 Injections, Intramuscular Injections, Engler Ion Therapy, Magnetic Field
Therapy, Detox Foot Bath, Physical Therapy Immersion Bath, Acupuncture: TCM, Auricular, Taiwanese;
Aromatherapy, Lymphatic Drainage, Cranial Sacral Therapy, Chiropractic Adjustment, Psychotherapy,
Fango Clay Therapy, Hyperbaric Chamber, Oxygen Therapy, Ultrasound, and Salt Bed or Salt Chamber
Therapy.
I understand and I am informed that as in the practice of all forms of heath care, including the practice of
Naturopathic, Chiropractic and traditional Chinese medicine, that there are some risks, contraindications
and benefits with evaluation and treatment with all of these therapies including, but not limited to:
Pain; discomfort; blistering; minor bruising; discoloration; infections; burns; loss of consciousness; deep
tissue injury from needle insertions, topical procedures, heat or frictional therapies, electromagnetic or
hydrotherapies; allergic reaction to prescribed herbs, supplements or prescription medications; soft tissue
or bone injury from physical manipulations and an aggravation of a pre-existing injury.
All female patients must advise their provider if they know or suspect that they are pregnant. Patients with
bleeding disorders, pace makers and cancer should also advise their provider of their overall health
condition.
Benefits may include restoration of the body’s maximal functioning capacity, relief of pain and symptoms
of disease, assistance in injury and disease recovery and prevention of disease or its progression.
I do not expect my doctor to be able to anticipate and explain all of the risks, contraindications and
complications, and I wish to rely on my doctor to exercise all judgment during the course of the
procedure, based on the known facts. I understand that it is my responsibility to request that my doctor
explain therapies and procedures to my satisfaction. I am aware that there are no guarantees concerning
the results of the intended treatment. I acknowledge that I have been provided ample opportunity to read
this document (or have it read to me) and other educational materials specific to the treatments or
procedures that I am to have, and I hereby give my oral and written consent to the evaluation and
treatments and wish this document to cover the entire course of treatments for my present condition or
future conditions for which I seek advice.
Patient’s name: (print)________________________________________________________________
Patient’s signature:____________________________________ Date __________________________
Parent or legal guardian: (if applicable) ________________________________________________ ___
Parent or legal guardian signature: ________________________Date __________________________
Doctor’s Name: (print)_____________________Doctor’s Signature / Initials: ____________Date _____