CLIENT INFORMED CONSENT AND DISCLOSURE STATEMENT FOR INTEGRATIVE AND FUNCTIONAL MEDICINE

AUTHORIZATION FOR INTEGRATIVE MEDICAL TREATMENT

By signing this form I authorize the Indigo Integrative Health Clinic, its providers, clinical staff (licensed to practice medicine in and under the laws of the state of District of Columbia) and its authorized administrative staff to obtain all medical information (to include, however, not limited to: interviews, results, medical records, physical examination, laboratory tests, biopsy results and/or radiographic x-rays and scans) in order to establish a clinical diagnosis to make a clinical diagnosis and decision to provide allopathic, adjunctive, complementary and/or naturopathic and functional medicine treatment. If a definitive allopathic diagnosis has not been made, I understand that Indigo Integrative Health Clinic must order the appropriate test(s) and or consultation(s) to confirm the diagnosis of the presenting symptoms. I further authorize the same such allopathic, adjunctive, complementary and/or naturopathic and functional medicine treatment and procedure needed to address my health problems and needs. I understand that the best efforts for diagnosis and treatment protocols shall be made and that there are no guarantees of treatment outcomes.

I have been advised of and offered the traditional (allopathic) treatment for my disorder and have been presented to the Indigo Integrative Health Clinic because such allopathic treatment(s) have failed me in the past or because I have a strong desire to avail myself of an integrative medical approach to treat my condition.

You knowingly, voluntarily, and intelligently assume all risks involved with using the CAM Methods or other therapies recommended by practitioners at Indigo Integrative Health Clinic. As a result of your assumption of these risks, you agree to release, indemnify, defend, and hold harmless practitioners and staff at Indigo Integrative Health Clinic and against any and all claims which you (or your representatives) may have for any loss, damage, or injury arising out of the adverse reactions to which you have been given notice or which may arise without the negligence of practitioners at Indigo Integrative Health Clinic, or in connection with the use of the CAM Methods or other therapies, or arising out of or in connection with any referrals to other practitioners. You further acknowledge that it is your responsibility to inform your primary care physician or any treating providers(s) and other health care providers concerning the therapies you receive from practitioners at Indigo Integrative Health Clinic so they can determine, within their professional competence, whether any harmful or adverse effects are possible given their treatment of your medical condition(s).

YOU HAVE CAREFULLY READ THIS FORM AND ACKNOWLEDGE THAT YOU UNDERSTAND IT. NO REPRESENTATIONS, STATEMENTS, INDUCEMENTS, ORAL OR WRITTEN, APART FROM THE FOREGOING WRITTEN STATEMENT, HAVE BEEN MADE. This form shall be interpreted under the District of Columbia law, and the District of Columbia will be the forum for any lawsuits filed under or incident to this form. If any portion of this form is held invalid, the rest of the document will be in full force and effect.

INFORMED CONSENT

I seek the medical and healthcare services of Indigo Integrative Health Clinic, PLLC, and its associates, employees, and other staff.

I understand that Indigo Integrative Health Clinic may use some diagnostic and treatment methods that are known as complementary, alternative or holistic that are not covered by Medicare and many other insurance plans. Many of these methods have not been accepted by mainstream medicine. Some of the characteristic qualities of complementary medicine that are used by Indigo Integrative Health Clinic are as follows:

• A person’s lifestyle including his or her diet, exercise patterns, sleep habits, stresses and interpersonal relationships are believed to be directly related to the development and maintenance of illness. Complementary medicine evaluates these factors and seeks to help the patient give up negative lifestyle patterns and establish more positive patterns regardless of age or type of medical problem.
• Although prescription and over-the-counter medications are used when the practitioner believes it is necessary, an attempt is first made to use products that are more natural and less aggressive to the body. These include nutritional supplements such as vitamins, minerals, enzymes, amino acids, essential fatty acids and/or herbs.
• In addition to recommending that the patient takes nutritional supplements by mouth, we frequently recommend that the patient receives a series of injections either intravenously or intramuscularly. It allows a high concentration of the substance into the bloodstream, which may be difficult if the substance is taken by mouth orally and the patient has (mal)absorption problems.
• For some patients, we recommend either classical homeopathy or complex homeopathy, which uses extremely small concentrations of animal, vegetable, or mineral substances to stimulate the body’s healing mechanisms. Although homeopathy is fairly well established in some European Countries, India and other countries worldwide, it is generally not accepted by consensus mainstream medicine in the United States.

The above represents some of the ways Indigo Integrative Health Clinic, PLLC may differ from other provider’s offices you have visited. Our programs are exclusively office based. We do not work in the hospital. You may be required to be under the care of one or more providers appropriate to your condition and situation. We are happy to cooperate with any provider who is willing to work with us.

I have read, understand, and agree to the foregoing. I agree that if I ever have a claim with respect to the services and treatments given to me by Indigo Integrative Health, PLLC, their providers, associates, employees and/or staff, that they shall be judged by the standards and principles of complementary, alternative, and holistic medicine and not by the standard and principles of mainstream and allopathic medicine. I understand that I have the right to review this Consent Form with an attorney, if I choose, before accepting any medical services from Indigo Integrative Health Clinic, PLLC. I have reviewed this consent form freely and willingly and understand its provisions. I recognize that Indigo Integrative Health Clinic, PLLC, will rely upon my signing of this document in order to accept me for evaluation as a patient. I acknowledge receipt of a copy of this Consent Form if I so choose.

For your heath consultations, you will be seeing our nurse practitioner, Snejana Sharkar, who has been practicing functional and integrative medicine for over a decade.

OUTCOME EXPECTATIONS

Assuming that we establish a good therapeutic relationship, I am quite optimistic that our work together will lead to an outcome that you would consider positive. However, you understand that the practice of medicine is not an exact science and acknowledge that there are and can be no guarantees as to the accuracy or outcomes of any diagnostic approaches or treatment recommendations that you receive from Indigo Integrative Health Clinic. After we see you and evaluate your situation, if we feel we cannot help you, we will inform you and will work to refer you to an appropriate practitioner or practice if necessary. We will work together to achieve the best possible results for you.

A holistic integrative approach to health and wellness can result in a number of benefits to you, including improving health issues and resolution of the underlying reasons that led you to seek treatment but working toward these benefits requires effort on your part in partnership with us. Integrative health requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. You will have to work both in and out of the treatment sessions. We will ask for your feedback and views on your treatment plan, its progress, and other aspects of the treatment plan and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation.

RISKS & BENEFITS OF ALTERNATIVE TREATMENTS

As with any intervention, there are risks associated with various CAM (Complementary and Alternative Medicine) Methods. While the energy medicine methods Indigo Integrative Health Clinic uses are gentle and considered non-invasive, it’s possible in our sessions together or on your own between sessions, to experience some physical discomfort or emotional distress after your energies have been stimulated and adjusted. Occasionally, some people have experienced dizziness, nausea, or anxiety as occasional side-effects from energy work. If any technique is uncomfortable or does lead to distress or discomfort, please tell your practitioner at once. We will stop immediately and can often provide a technique to rebalance the energies whose stimulation is causing distress or discomfort. After the session your practitioner will suggest self-care exercises that may help to stabilize and enhance the work that was done.

Herbs, homeopathic remedies, and nutritional supplements are traditionally considered safe. However, it’s possible to experience an unanticipated or unpleasant effect from the consumption of herbs, homeopathic remedies, and nutritional supplements. You agree to your practitioner or a member of our staff if you experience any unanticipated or unpleasant effects from consuming herbs, homeopathic remedies, or nutritional supplements. In addition, the use of nutritional supplements, herbs, and homeopathic remedies for patients already using pharmaceutical medication (drugs) is usually safe, yet some potentially harmful interactions could occur. For this reason, it is important to keep us fully informed about all medications and nutritional supplements, herbs, and homeopathic remedies you may be taking.

You and your practitioner will discuss the risks and benefits of including or foregoing the suggested diagnostic and therapeutic approaches offered, to enable you to decide to include or forego these approaches in your treatment regimen. You should be aware that some of the diagnostic and treatment option offered:

• May be nonconventional or nonstandard, or may involve a drug or device that is used for off-label purposes, or to support your health and well-being using energetic means;
• The safety, efficacy, and mechanisms for some of these therapies may not be completely known even though limited information from clinical trials may exist, and that some of these therapies could adversely interact with medications you are currently taking or that are prescribed by your provider(s) or other health care provider(s), or with procedures such as surgery;
• It may be difficult, given the current state of medical science, to predict results with respect to inclusion of these therapies; and the fact that therapies we have discussed may be emerging therapies that are not uniformly considered proven or acceptable, despite clinical data;
• It is important to continue your primary medical care through your primary care physician, as appropriate, and to ensure that inclusion of the CAM Methods or other therapies recommended does not cause delay in, or discourage conventional diagnosis of (or care for) any medical condition;
• We may refer you to other practitioners, including CAM providers and allied health practitioners to offer helpful therapeutic services, although we cannot guarantee results from their care and we are not responsible for the quality of care they may or may not be able to provide you.

You understand and agree that it’s not possible to anticipate and explain all possible risks and complications of treatment from the CAM Methods and other therapies offered at Indigo Integrative Health Clinic. By signing this document you acknowledge that you are relying on Indigo Integrative Health Clinic to exercise judgment during the course of treatment which is thought of at the time, based upon the facts then known, is in your best interest.