» Bio Health Center's Informed Consent
PATIENT ACKNOWLEDGMENTS
The legal standard of care established in Nevada and most of the rest of the United States requires that each patient be informed of the risks and benefits of any medical treatment or surgical procedure before agreeing to undergo treatment. The customary method for doing this is through the use of a written "INFORMED CONSENT FORM " that is signed by the patient or their legal guardian. In addition, the laws and state regulations of Nevada recognize and license the practice of Homeopathic Integrative medicine as a separate specialty or "school of practice." Although there is an officially recognized United States Pharmacopoeia (listing) of Homeopathic remedies (medications), federal medical entitlement programs, including Medicare™, Medicaid™, Champus™ and all others do NOT currently cover Homeopathic Integrative medical services. In addition, private insurance and so-called health maintenance or "prepaid"plans (HMO's, PPO's, IPO's, etc.) MAY NOT, and usually DO NOT cover such care. In addition, "Health Care" (regular checkups, prevention, wellness services, health counseling, etc.) is NOT the same as "Medical Care" (Disease or Sickness Care). Almost all "third party payer" plans (private insurance, Medicare™, Medicaid™, Champus™, HMO's, PPO's, IPO's, etc.) are really for "Medical Care" and do NOT cover Health Care, Health Maintenance, most preventive care or wellness counseling.
Dr. Edwards and the certified staff of Bio Health Center agree with the legal concept of "informed consent." Because we practice Homeopathic Integrative medicine, we also believe that each patient should understand their financial responsibility when they exceed the terms of their insurance or health maintenance legal contract. For these reasons, all of our informed consent documents and patient acknowledgments for federal anti-fraud protection and financial responsibility disclosures are given below for your review. In addition, the federal Health Insurance Portability and Accountability Act of 1999 (HIPAA) mandates strict privacy regulations for insurers and certain medical providers. While this act does NOT apply to Dr. Edwards or Bio Health Center, a summary is provided for informational purposes. At Bio Health Center, each patient must execute the appropriate consent(s) and acknowledgments before Homeopathic Integrative medical services can be provided.
| David A. Edwards, MD, HMD, Ltd |
Jean Malik, AHP
Advanced Homeopathic Practitioner |
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WORK TEL.# |
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RELIGIOUS PREFERENCE: |
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Please list any and ALL KNOWN MEDICATION ALLERGIES
(Penicillin, Novocain, TM etc.)
Do you have pets?
What Kind?
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HOMEOPATHIC MEDICINE - ACKNOWLEDGMENT
I have been informed/understand that David A. Edwards, MD, HMD and Jean Malik, AHP practice Homeopathic, Nutritional, Orthomolecular, Neural Therapeutic, Herbal, Neural Integrative and Preventive Medicine under licensing authority of the Nevada State Board of Homeopathic Medical Examiners. I have been informed and understand that under current Nevada Revised Statutes (NRS) licensed Homeopathic physicians are PROHIBITED from practicing allopathic medicine and their prescribing authority is LIMITED to methods approved in NRS 630A.040. I have been informed and understand that Homeopathic medicine is currently NOT available at any Nevada hospital, and that due to this our practitioners do NOT practice at any area hospital, including emergency care. I understand that Homeopathy, medical acupuncture, electro-acupuncture, herbal therapy, neural therapy, neuro integrative therapy, chelation therapy, bio-oxidative therapy and some instrumentation may not be accepted by some insurance companies, the FDA, or the AMA. I have been informed and understand that the Ninth Amendment to the U.S. Constitution reads (in part): "the enumeration in the Constitution of certain rights shall not be construed to deny or disparage others retained by people." I hereby notify the federal and Nevada state governments, agencies, boards, courts and the FDA that I reserve following rights under the Ninth Amendment to the US Constitution: the right to 1. the physician of my choice, 2. an informed choice of all options for personal health care, 3. a drug-free, surgery-free existence, 4. use nutritional supplements based on my own opinion of their need and action, 5. prevent illness and disease using methods of my own choice and 6. self-determination in all matters of health and medical care.
FEDERAL ANTI-FRAUD DISCLAIMER
I have been informed and understand that Dr. Edwards and the staff of Bio Health Center practice Homeopathic, Nutritional, Orthromolecular, Neural Therapeutic, Herbal, Neuro-Integrative and Preventive Medicine under licensing authority of the Nevada Board of Homeopathic Medical Examiners. I understand that the determination as to whether any and all medical/health services provided are "covered" by my private insurance/health plan will be made after these services have been provided. I understand that I am fully responsible for payment for any and all medical/health services provided by Edwards/Malik and I will attest in writing to this at each visit. I understand that payment is due at the time of service unless specific arrangements were made in advance and that credit can be obtained by using Mastercard™ or Visa™. I understand that any outstanding balance owed will be subject to a 1.5% monthly interest charge.
NOTICE TO ALL MEDICARE™ PATIENTS - ACKNOWLEDGMENT
I have been informed that MEDICARE™ does NOT COVER ANY SERVICES provided by Edwards/Malik, including medical acupuncture, homotoxicology, nutritional therapy, electro-acupuncture, chelation therapy, neural therapy, bio-oxidative therapy, and/or preventive medicine. Although I will not be reimbursed for the above medical services, I agree to said services and agree to pay for these services. I understand payment is due at the time of service unless specific arrangements were made in advance, that credit can be obtained by using Mastercard™ or Visa™ and that any outstanding balance owed will be subject to a 1.5% monthly interest charge.
FEDERAL HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) AND GENERAL AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION - ACKNOWLEDGMENT: David A. Edwards, MD, HMD, LTD does NOT transmit ANY health care claims information electronically. Therefore, we do NOT "qualify" as a "covered entity" under the provisions of the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA or PL104-191). However, we do agree with protecting the absolute privacy of ALL personal-private health information in our custody, and we do fulfill ALL mandated federal requirements of HIPAA in our handling and care of ALL personal-private health information. An outline of HIPAA mandates is provided on the reverse side of this form. I authorize the release of any and all medical information to my insurance/health plan administrator, any and all physician(s) I may be referred to and/or any person(s) legally designated by me.
I have read, understand and acknowledge ALL of the above:
Signature (Patient/Guardian if minor)
Date: * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
The Health Insurance Portability and Accountability Act of 1996 (HIPAA/PL104-191) became effective on April 14, 2001. Included the federal law is a "Health/Medical Information Privacy" section. This law applies to any "ENTITY" that use computers to transmit health claims information. "ENTITY" is defined as a "Health Plan" (HMO's, insurers, group health plans, employee benefit plans), Health Care Clearinghouse (an entity that processes health information going from a health care provider to a payer and certain Health Care Providers those who use computers to transmit health claims information). Covered health care providers must generally obtain the patient's consent prior to using or disclosing protected health information to carry out treatment, payment or health care operations. However, providers may condition treatment on patient's providing consent form. In addition, covered entities must make reasonable efforts to limit protected health information to the minimum necessary to accomplish the intended purpose of the use, disclosure or request for health information from another. This standard does not apply to treatment.
Individuals have a right to see and obtain a copy of their own health information, including documentation of who has had access to this information. There are also limited exceptions to when a patient can access their own information, such as when such access would endanger the life or safety of any individual. Nevada already statutorily grants a patient the right of access to his health records in the possession of health care providers, including physicians, hospitals and pharmacists. However, Nevada does not have a general, comprehensive statutory prohibition against the disclosure of confidential medical information. Individuals also have the right to request amendment or correction of health information that is incorrect or incomplete. Health plans and covered health care providers are required to provide written notice of their privacy practices, including a description of an individual's rights with respect to protected health information (such as the right to inspect and obtain a copy of health records) and the anticipated uses and disclosures of this information that may be made without the patient's written authorization. A covered entity may not condition the provision of services or payment on the receipt of the authorization.
Health information may be disclosed for a number of purposes without any patient authorization including, but not limited to: public health activities, research, and fraud investigations. For all other purposes (other than those listed), patient authorization is required. Covered entities can disclose protected health information without a patient's authorization only to researchers whose protocol has been reviewed and approved by an Institutional Review Board (IRB) or a "privacy board."
Only the use and disclosure of "protected health information" is covered. In order to be considered "protected health information" under the regulations, information must: (1) Relate to a person's physical or mental health, the provision of health care, or the payment of health care; (2) Identify, or could be used to identify, the person who is the subject of the information; (3) Be created or received by a covered entity; and (4) Which is transmitted or maintained in any form or medium. Covered entities may create and use "de-identified information," health information which has been stripped of elements that could be used to identify individual subjects.
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MEDICAL RECORD AMENDMENT REQUEST
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Click here to download form in Word format. |
The federal Health Insurance Portability and Accountability Act (HIPAA) of 2000 mandates that patient's have the right to request changes in their protected health care information. Technically, HIPAA does NOT apply to David A. Edwards, MD, HMD or Bio Health Center since neither qualifies under the law as a "covered entity." However, Dr. Edwards agrees with the right to request necessary corrections in private health information and voluntarily complies with HIPAA, despite his non-covered status under the law. The law states HIPAA "covered entities" have 60 days to respond to requests for changes or amendments to private medical records and that such requests may be required to be "in writing." If you wish to have your private medical record created by Dr. Edwards and/or Bio Health Center corrected or amended please complete and return the following information (please PRINT):
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Please explain the information you wish to be changed or corrected:
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Please list the reason(s) for the request and any suggested language you would like used: |
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Please provide the name(s), address(es) and phone number(s) of any
and all other "entities" you wish to inform of the corrected
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Signature:
Date of Request: Please be aware that a legal denial for this request is allowed under federal law if: 1) the information on file is correct as recorded, 2) another federal law prohibits releasing your information to you, 3) the information correction being requested is not part of our records or 4) our office did not create the original record you wish to correct or amend.
Reason(s) for denial of request:
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DAVID A. EDWARDS, M.D., H.M.D.
LTD PRACTICE LIMITED TO INTEGRATIVE MEDICINE |
615 Sierra Rose Drive, Suite 3
Reno, NV 89511 (775) 828-4055 Fax (775) 828-4255 |
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INFORMED CONSENT FOR CHELATION
THERAPY
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hereby give my consent to Dr. David Edwards
and the staff of Bio Health Center to administer intravenous chelation
therapy ("Chelation Therapy") for the specific purpose of treating
and/or preventing athero-arteriosclerotic degenerative vascular disease,
heavy metal burden and/or the treatment/prevention of other degenerative
diseases. I understand that chelation therapy is FDA approved and is standard
treatment for heavy metal toxicity. I understand that it is "investigational"
when used for any other "off-label" use, but that the off label
use of any FDA approved drug is legal, common and encouraged by the FDA.
I have been informed and understand that the use of chelation therapy
for degenerative vascular disease is controversial and the view that it
is beneficial for the treatment of such related disorders is accepted
by a minority of physicians in the US I understand that the majority of
US physicians presently consider such treatment as "investigational,"
even though it has been published in a major textbook of cardiovascular
therapy as being beneficial (Cardiovascular Drug Therapy, edited by Franz
Messerli, chapter 175, page 1613-17). I understand that Dr. Edwards and
the certified staff of Bio Health Center believe that chelation therapy
does have positive clinical benefit and may be useful in my particular
case. I have been informed about and understand that there may be alternative
treatments for vascular disease, including surgical bypass grafting, angioplasty,
EECP and/or pharmaceutical therapy. These alternatives have been explained
to my full and complete satisfaction.I understand that the benefits of chelation therapy are much greater if a healthy lifestyle, regular exercise, proper diet, avoidance of luxury toxins (tobacco, etc.) and nutritional supplementation are used. I understand that an initial series of thirty (30) treatments is usually administered over 15 weeks (twice weekly). I have been informed and understand that chelation therapy is routinely maintained or repeated periodically in the future to maintain or improve benefit. I understand that certain nutritional supplements are required during the entire series of chelation treatments. These include, but may not be limited to, Bio Health Plus™ multivitamin and mineral supplement, Bio Health™ coenzyme Q10/L-carnitine, Bio Health folic acid/B12/B6™ and DHEA. I understand that additional supplements may be needed on an individualized basis, and these will be explained by Dr. Edwards or the certified staff, if necessary. I understand that in some cases prescription pharmaceuticals, such as high blood pressure medicine, cholesterol lowering drugs, etc. may be recommended. In addition, I understand that homeopathic, bio-oxidative, herbal, acupuncture, neuro-muscular integrative and neural therapies may add additional benefit when used on an individualized basis. I understand that these therapies may be part of my overall treatment plan and will be explained by my physician if necessary. I understand that I may discontinue treatment at any time without incurring further expense after I have notified and directed my physician that I have decided to discontinue treatment.
I have been informed and understand the possible risks and potential side effects including, but not limited to, discomfort at the infusion site, phlebitis (inflammation of vein), allergic reaction, thinning of blood (bruising), mineral loss, congestive heart failure, transient low blood sugar or calcium, muscle cramps, fatigue and/or dizziness. I understand that kidney problems may result from chelation therapy and that laboratory tests of kidney function (blood/urine tests) are required before and regularly during chelation therapy to prevent damage to the kidneys from excessive heavy metal excretion. I have been informed that circulation and possibly heart testing will be done before and periodically after chelation therapy to evaluate the need for treatment and/or to objectively monitor any improvement. I understand that additional tests, including, but not limited to, ECG (EKG), chest x-ray, toxic mineral assessment and blood tests to monitor cholesterol, minerals, kidney function, etc. will be performed. An explanation for the necessary tests has been provided to my satisfaction by my physician. I understand that all costs for testing are separate from and in addition to the cost of chelation therapy. I agree to execute a medical release so all previous medical records from any and all previous treating physician(s) may be obtained as needed. I have discussed openly any known kidney disorder. I understand I should not undergo chelation therapy if I am pregnant, or suspect that I may be pregnant. I understand that chelation therapy may reactivate arrested tuberculosis (TB) and I have discussed openly any knowledge of previous TB or exposure. I have not been asked to discontinue my care with any other physician. I understand the nature of the proposed treatment and the risks and dangers have been explained to me to my full satisfaction.
I have been informed and understand that chelation therapy and all physician services, laboratory testing and vascular/heart testing associated with chelation therapy and NOT COVERED by MEDICARE™ and MAY NOT QUALIFY FOR COVERAGE by private insurance. Due to these facts I understand that I am responsible for all costs involved with chelation therapy. While I understand that NO warranties, assurances or guarantees of successful treatment have been made to me, I have decided to undergo this treatment after having considered the information contained in this document, the information provided to be by my treating practitioner and any additional educational/consumer information I have reviewed about chelation therapy. I acknowledge that I have had ample opportunity to ask any questions of my physician with respect to the proposed chelation therapy and any and all procedures to be utilized related to it. All of my questions have been answered to my full and complete satisfaction. I understand that I will receive a copy of this signed informed consent if I request it.
Patient Name (Print):
Date: Patient Signature:
Witness (Print):
Date: Witness Signature:
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DAVID A. EDWARDS, MD, H.M.D.
LTD PRACTICE LIMITED TO INTEGRATIVE MEDICINE |
615 Sierra Rose Drive, Suite 3
Reno, NV 89511 (775) 828-4055 Fax (775) 828-4255 |
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INFORMED CONSENT FOR BIO-OXIDATION
THERAPY
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I
hereby give my consent to Dr. David A. Edwards
and the staff of Bio Health Center to administer Bio-Oxidation Therapy,
consisting of oxygen, intravenous hydrogen peroxide or Phosphatidyl Choline
and/or medical ozone alone or in cyclic combination. I have been informed
and under stand that bio-oxidation methods of treatment for athero-arteriosclerotic
vascular and other degenerative diseases are controversial and the view
that it is beneficial for the treatment of such related disorders is accepted
by a minority of physicians in the US I understand that a majority of
US physicians presently consider such treatment as "investigational."
I understand that my treating physician believes that this therapy does
have positive clinical benefit and may be useful in my particular case.
I have been informed about and understand that there may be alternative
treatments for vascular disease, including surgical bypass grafting, angioplasty
and/or pharmaceutical therapy. These alternatives have been explained
to my full and complete satisfaction.I understand that the benefits of bio-oxidation therapy are much greater if a healthy lifestyle, regular exercise, proper diet, avoidance of luxury toxins (tobacco, etc.) and nutritional supplementation are used. I understand that an initial series of daily or weekly treatments is administered, depending on which form of bio-oxidation therapy is used. I have been informed and understand that extremely low doses (in the Homeopathic microgram or thousandths of a milligram range) of hydrogen peroxide and/or ozone are used. I understand that the side effects of such low doses may include pain at the infusion site, local redness or local inflammation of the vein. In addition, ozone can aggravate a high thyroid condition and should NOT be used when such an untreated condition exists. I have been informed that the prescription medication Captopril (Capoten™ Capozide™) should NOT be taken while receiving ozone and if I am currently on this medication my physician will substitute a compatible medication if necessary. I understand that anti-oxidant nutritional supplements including, but not limited to, vitamins A,C,E, beta carotene and the mineral selenium are required during a series of bio-oxidation treatments. I understand that when used in conjunction with chelation therapy, the required supplements for both protocols are to be taken. I understand that laboratory testing to monitor the effects of bio-oxidation therapy including, but not limited to, biological terrain analysis (BTA), will be required before, after and possibly during bio-oxidation treatment. An explanation for the necessary tests has been provided to my satisfaction by my physician. I understand that all costs for testing are separate from and in addition to the cost of chelation therapy. I agree to execute a medical release so all previous medical records from any and all previous treating physician(s) may be obtained as needed.
I understand that, with the exception of oxygen therapy, bio-oxidation therapy is NOT currently FDA approved. Because of this bio-oxidation therapy and laboratory tests related to its use are NOT covered by MEDICARE™ and will usually NOT be covered by private insurance. I also understand that MEDICARE™ and private insurance usually restrict payment for oxygen therapy to what they determine as "medically necessary," and bio-oxidative oxygen therapy is NOT covered by MEDICARE™ and is usually NOT covered by private insurance. Due to these facts I understand that I am responsible for all costs involved with chelation therapy. While I understand that NO warranties, assurances or guarantees of successful treatment have been made to me, I have decided to undergo bio-oxidation treatment after having considered the information contained in this document, the information provided to be by my treating physician and any additional educational/consumer information I have reviewed about bio-oxidation therapy. I acknowledge that I have had ample opportunity to ask any questions of my physician with respect to the proposed bio-oxidation therapy and any and all procedures to be utilized related to it. All of my questions have been answered to my full and complete satisfaction. I have not been asked to discontinue my care with any other physician. I understand the nature of the proposed treatment and the risks and dangers have been explained to me to my full satisfaction. I understand that I will receive a copy of this signed informed consent if I request it.
Patient Name (Print):
Date: Patient Signature:
Witness (Print):
Date:
Witness Signature:
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DAVID A. EDWARDS, MD, H.M.D.
LTD PRACTICE LIMITED TO INTEGRATIVE MEDICINE |
615 Sierra Rose Drive, Suite 3
Reno, NV 89511 (775) 828-4055 Fax (775) 828-4255 |
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INFORMED CONSENT FOR ULTRAVIOLET
BLOOD IRRADIATION THERAPY
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I hereby give my consent to Dr. David A. Edwards and the staff of Bio Health Center to administer Ultraviolet Blood Irradiation Therapy (UVBI Therapy), scientifically referred to as Extra-Corporeal Photophoresis. I have been informed and understand that this method involves removing a small volume of my own blood (average = 1.5cc/pound body weight to a maximum of 250cc's) under sterile conditions, briefly exposing that blood to selected frequencies of Ultraviolet Light and re-infusing the blood back into the body. The blood is also treated with a very small amount of temporary acting anti-coagulant (heparin). I understand that UVBI is currently approved by the U.S.F.D.A. for treating certain forms of lymph cancer and psoriasis.
I understand that UVBI therapy is used clinically as both a specific (ie psoriasis, lymph cancer) and non-specific (chronic infections, chronic fatigue, auto-immune diseases, scleroderma, etc.) immune modulating therapy. Certain forms of cancer, auto-immune diseases, infections and tissue transplant rejection have all been published as benefiting from Photophoretic UVB therapy. I understand that the nonspecific use of UVBI is "investigational" and is therefore NOT COVERED BY MEDICARE OR MEDICAID and MAY NOT BE COVERED by private insurance. I have also been informed that the combination of UVBI therapy with another type of bio-oxidative treatment (hydrogen peroxide, ozone) is commonly used and will require a separate informed consent if my treatment includes this method. I understand that the fees for UVBI therapy DO NOT COVER the costs of any additional bio-oxidative therapy. I understand that UVBI therapy is usually administered once or twice weekly for a series (10 to 20) of treatments, depending on the condition being treated. I understand that the side effects of UVBI therapy include minor bruising at the injection site, potential minor bleeding from the heparin, mild temporary "healing reactions" (low grade fever, minor muscle aches or joint aches), potential for secondary infection, possible prescription drug-UVBI interaction (ie sulfa drugs, tetracyclines, phenothiazines) and the rare possibility of photoallergy in the case of allergy to sunlight. I have notified my physician of ALL PRESCRIPTION MEDICATIONS I am currently taking prior to UVBI therapy being administered. I also understand that I am to STOP any and all antioxidant supplements (ie vitamins A,C,E, beta-Carotene, Coenzyme Q10, Lipoic acid, Proanthocyanidins, etc.) 24 hours BEFORE AND AFTER receiving UVBI therapy.
I have READ, UNDERSTAND AND CONSENT to the above.
Signature:
Date: Witness:
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| DAVID A. EDWARDS, MD, H.M.D.
LTD PRACTICE LIMITED TO INTEGRATIVE MEDICINE |
615 Sierra Rose Drive, Suite 3
Reno, NV 89511 (775) 828-4055 Fax (775) 828-4255 |
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CONSENT FOR PARENTERAL (IV/IM)
NUTRITIONAL, VITAMIN AND/OR MINERAL THERAPY
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The use of intravenous and/or intramuscular nutrients (called parenteral nutrition), including amino acids, vitamins, minerals and other nutrients allows direct access to the metabolism without requiring proper or optimal functioning of the organs of digestion, including stomach, small intestine, large intestine, liver and/or pancreas as well as the entire ensemble of digestive enzymes. The use of nutrients in this way is referred to scientifically as ORTHOMOLECULAR MEDICINE. In some cases the nutrients are used to induce optimal function of the metabolism. In other cases the nutrients may be used in higher than replacement amounts to achieve a general or specific metabolic effect. For example, higher dose of the B vitamin "niacin" (vitamin B-1) is used medically to lower cholesterol and triglycerides. Similarly, high doses of vitamins B-1, B-6 and Folic acid are used to lower elevated blood Homocysteine levels (levels of Homomcysteine above 9 ng/dl are associated with a progressively increasing risk for heart attack, stoke and/or peripheral vascular disease, also called "hardening of the arteries"). In addition, the use of intravenous nutrition, including amino acids, vitamins, tropic factors and/or minerals is common in many chronic, degenerative diseases as general metabolic support for optimal self-healing. Orthomolecular medicine is also commonly used to help fight infections, allergies and the effects of stress. Finally, parenteral nutritional methods are commonly used for correcting sub-clinical problems and for disease prevention.
Although the use of Orthomolecular Medicine is completely legal in the state of Nevada under Nevada Law (Nevada Revised Statutes 630A.040(2), in many cases the treatments are NOT COVERED BY MEDICARE™ and may NOT be covered by private insurance. In the case of private insurance, however, there is no way of knowing whether or not the treatment will be covered until the patient submits the claim for reimbursement. The receipt provided by Bio Health Center is complete with the treatment used, appropriate diagnosis and ALL other information legally required for the insurer to process the claim as submitted. Therefore, patients are encouraged to submit their claims for reimbursement. SIDE EFFECTS are generally mild and may include pain an/or irritation at the injection site, brief light headedness, dizziness, warmth, flushing, transient nausea or rash or, rarely, true allergy. Any and all questions about my use of Orthomolecular Medicine methods have been answered to my complete satisfaction by my physician and/or the staff of Bio Health Center.
I HAVE READ, UNDERSTAND AND GIVE MY CONSENT TO THE ABOVE.
Signature:
Date: Witness:
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DAVID A. EDWARDS, MD, H.M.D.
LTD PRACTICE LIMITED TO INTEGRATIVE MEDICINE |
615 Sierra Rose Drive, Suite 3
Reno, NV 89511 (775) 828-4055 Fax (775) 828-4255 |
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INFORMED CONSENT FOR INJECTION LIPO-SCULPTING©
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I consent to Dr. David Edwards and/or the staff of Bio Health Center administering Homeopathic-Integrative Injection Lipolysis©. I understand that Lipo-Sculpting© (Injection Lipolysis©) is intended to produce effects similar to surgical liposuction without anesthesia or invasive surgery risks. I understand that multiple injections are made subcutaneously of homeopathic and nutritional (orthomolecular) preparations for localized"Lipo-Sculpting©" of various specific and separate areas of excessive body fat accumulation (under eyes, chin, back of the arms, breast fat reduction, "love handles," abdomen, buttocks, thighs and/or around knees) and is used for cosmetic-aesthetic purposes. I understand that depending on the degree of excess fat accumulation to be reduced and the specific area of the body involved, a series of injections is administered every 10 to 14 days for a total of 3 to 10 or more sessions. I understand that the benefits of Homeopathic-Integrative Lipolysis Injection therapy are much greater if regular exercise and fat loss diet are also followed. I understand that additional Homeopathic-Integrative support measures, therapy and/or prescription pharmaceuticals may also be recommended on an individualized basis. I understand that these will be recommended as part of an overall treatment plan. I understand the SIDE EFFECTS of Injection Lipolysis© are generally mild and may include minor bleeding and/or bruising at the injection sites, temporary mild pain or discomfort, localized redness, itching and/or irritation, potential secondary infection, brief light-headedness or, rarely, true allergy. I understand that tenderness and bruising may last from one to seven or more days. I understand that the nutritional-orthomolecular substance is derived from soy and to my knowledge I am not allergic to soy. I understand that Nevada Revised Statutes (NRS 0.040) define three schools of medical practitioners: "allopathic" (MD), "osteopathic" (DO) and "homeopathic" (HMD), and that they may differ in their approach to diagnosis and/or treatment of disease. I have been informed and understand that due to its Homeopathic, nutrient nature and natural occurrence, the clinical use of Homeopathic Liposculpting© therapy falls under Homeopathy and "Orthomolecular Therapy" as defined in Nevada law (NRS 630A.040) and Nevada Administrative Code (NAC 630A.014(1)(d). I understand that Orthomolecular preparations are over-the-counter nutrient and is generally not covered by any federal entitlement program (Medicare, Medicaid, Champus, etc.) and most private insurance or pre-paid managed ("HMO-IPA-PPO") care. I understand that "Lipo-Sculpture©" is performed as a cosmetic procedure it is not covered by any private insurance. I understand that I am responsible for all costs involved. I understand that the fee quoted for each injection session includes a volume of up to 10 cc's of solution. Additional solution will increase the fee. I understand the nature of the proposed treatment and the risks have been explained to my full satisfaction. I have had ample opportunity to ask any questions of my physician with respect to the proposed course of therapy and all questions have been answered to my full satisfaction. I understand that NO warranties, assurances or guarantees have been made. I understand that I may discontinue treatment at any time.
I HAVE READ, UNDERSTAND AND GIVE MY CONSENT TO THE ABOVE.
Patient Name (Print)________________________________ Date______________
Patient Signature___________________________________
Witness _________________________________________ Date_______________
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DAVID A. EDWARDS, MD, H.M.D.
LTD PRACTICE LIMITED TO INTEGRATIVE MEDICINE |
615 Sierra Rose Drive, Suite 3
Reno, NV 89511 (775) 828-4055 Fax (775) 828-4255 |
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INFORMED CONSENT FOR MESOTHERAPY
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I consent to Dr. David Edwards and/or the staff of Bio Health Center administering Homeopathic-Integrative Mesotherapy. I understand that multiple injections are made subcutaneously of homeopathic, nutritional (orthomolecular) and or pharmaceutical preparations for aesthetic and/or therapeutic effects on the body, including, but not limited to, reducing cellulite deposits, localized body fat deposits, skin wrinkling, baldness, rejuvenation of facial and localized body wrinkled skin, as well as for the following specific medical conditions (please list ____________________________________________). I understand that depending on the specific problem , degree of the problem and the specific area(s) of the body involved, a series of injections is administered every 3 to 14 days for a total of 5 to 15 or more sessions. I understand that the benefits of Mesotherapy are much greater if specific medical recommendations, regular exercise and fat loss diet are also followed. I understand that additional Homeopathic-Integrative support measures, therapy and/or prescription pharmaceuticals may also be recommended on an individualized basis. I understand that these will be recommended as part of an overall treatment plan. I understand the SIDE EFFECTS of Mesotherapy are generally mild and may include minor bleeding and/or bruising at the injection sites, temporary mild pain or discomfort, localized redness, swelling, itching and/or irritation, potential secondary infection, brief light-headedness or, rarely, true allergy to nutrients, enzymes and/or pharmaceuticals, if used. I understand that tenderness and bruising may last from one to seven or more days. I understand that the nutritional-orthomolecular substances used are derived from soy and egg and to my knowledge I am not allergic to these. I understand that Nevada Revised Statutes (NRS 0.040) define three schools of medical practitioners: "allopathic" (MD), "osteopathic" (DO) and "homeopathic" (HMD), and that they may differ in their approach to diagnosis and/or treatment of disease. I have been informed and understand that due to its Homeopathic, nutrient nature and natural occurrence, the clinical use of Homeopathic Mesotherapy therapy falls under Homeopathy and "Orthomolecular Therapy" as defined in Nevada law (NRS 630A.040) and Nevada Administrative Code (NAC 630A.014(1)(d). I understand that Orthomolecular preparations are over-the-counter nutrient and is generally not covered by any federal entitlement program (Medicare, Medicaid, Champus, etc.) and most private insurance or pre-paid managed ("HMO-IPA-PPO") care. I understand that when Mesotherapy is performed as a cosmetic procedure it is not covered by any private insurance. I understand that I am responsible for all costs involved. I understand the nature of the proposed treatment and the risks have been explained to my full satisfaction. I have had ample opportunity to ask any questions of my physician with respect to the proposed course of therapy and all questions have been answered to my full satisfaction. I understand that NO warranties, assurances or guarantees have been made. I understand that I may discontinue treatment at any time.
Patient Name (Print):
Date: Patient Signature:
Witness (Print):
Date: Witness Signature:
Name________________________________________ Age_______ Date_______________
Name of Primary Care Physician_________________________________________________
Who referred you to this office?__________________________________________________
Are you allergic to soy, egg or any medication(s) (please list)?__________________________
__________________________________________________________________________
Are you currently being treated for any health or medical condition (please list)?_____________
__________________________________________________________________________
Are you currently taking any prescription drugs (please list)?____________________________
___________________________________________________________________________
To your knowledge, do you have: ______ a heart murmur; ______ easy bleeding; ______ any type of chronic infection?
If yes to any of the above, please provide details: ____________________________________
__________________________________________________________________________
Have you had or do you now have any of the following medical conditions or medical problem(s) of any kind? If so, please discuss them with the physician:
Heart problems_____ High blood pressure______ Lung Disease_______ Diabetes_______
Bleeding disorder______ Nerve problems______ Kidney problems______ Hepatitis______
Chronic fatigue_______ Fibromyalgia______ Endocrine disorder_______ Cancer_________
Blood transfusions______ Illegal drug use______ HIV/AIDS_____ Artery/Vein problems______
If yes to any of the above, please include details or any other medical information you consider relevant, if needed:____________________________________________________________
__________________________________________________________________________
Are you currently attempting a weight loss program? ________ If yes, what type of program(s) have you or are you using?____________________________________________________
How long have you had the current problem? ______________________________________
Please indicate area(s) of interest for Mesotherapy by using numbers to indicate which area(s) are of most importance to you:_____ Cellulite (locations?_________________________), Skin Wrinkling _________ (face_______, other areas (please list)_______________________, Balding _________, Other _________________________________________________
Do you have any specific questions or concerns regarding the Mesotherapy?
__________________________________________________________________________
__________________________________________________________________________
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"No where in today's managed care, third party, media circus does anyone present the the patient and clinical practitioners philosophy... For years I listened to the insurers, managers, experts, professors, news pundits, bureaucrats and opinion makers. But I ultimately realized that I still had to sleep at night. From all third party perspectives any clinical practice is, in essence, 'anecdotal.' So now I listen first and foremost to my conscience. I had good teachers, good mentors and loyal patients as well. Although I think 'science' is important, technology, politics and economics are not science. The professional oath I took upon becoming a physician was to relieve patient suffering, honor those who taught me, teach those willing to learn and reveal no information shared with me in confidence. It didn't have anything to do with third parties. That oath is our philosophy at Bio Health Center..."
- David A. Edwards, MD, HMD
