Naturopathic Medicine Treatment Consent Form

(Filled by the patient or guardian)

First Name: ______________________________ Last Name: ___________________________________

Home Address: _______________________________________________ Tel: ____________________

Date of Birth: _____________ Age: _______ Occupation: ______________________________________

Email Address: ________________________________________________________________________

Patient’s Declaration

1. I take sole responsibility for my consent to follow the health advice and treatment
suggested by _____________________________________________________________
2. I authorize ______________________________ to perform/administer naturopathic
treatment/procedure(s) using herbal medicine, acupressure, colour therapy, clinical
massage, hydrotherapy, aromatherapy, reflexology, various forms of energy medicine,
nutritional therapy, detoxification, naturopathic health assessment and therapeutic
tools/machines and lifestyle counseling or any other natural treatment that he/she
considers advisable in his/her opinion, judgement and conclusion.
3. The nature and purpose of the treatment, possible methods of treatment, alternate
methods of treatment, the risks involved and the complications are fully explained to
me by the above-named doctor.
4. It is my responsibility to comply with the therapies recommended.
5. I acknowledge that no absolute guarantee has been given to me as to the results that
may be obtained.
6. I understand that when my naturopathic doctor is unable to attend to me, my
healthcare needs may be administered by an associate who is a member of my doctor’s
integrative health team without preparing another consent form.
7. I understand that my medical records can only be released to my naturopathic doctor’s
integrative health team. All other transmission will require a fresh consent from me.
8. I am aware that there will be no refunds on services rendered or remedies supplied to
me during the course of my treatment unless my doctor decides otherwise.

I certify that I have read and fully understood the above consent to treatment and that this
form was filled and freely signed by me prior to the commencement of treatment.
Signature of Patient: ________________________Date: ________________________________
Name & Signature of Witness _______________________________________ Date: _________
*For minors and patients incompetent to give consent,
Parent or Guardian name & Signature __________________________________Date ________