Informed Consent Form Sample

You are here:

Informed Consent Form Sample

Informed Consent and
Additional Information About Dr. Doni’s Services

Donielle Wilson, ND graduated from a five-year Naturopathic Medical Program at an accredited Naturopathic Medical School, Bastyr University in Seattle, Washington. She attained a doctorate degree as a Doctor of Naturopathic Medicine and a certificate in midwifery. Dr. Wilson is licensed as a Naturopathic Physician in Washington State and Connecticut. She received Bachelor’s Degrees in nutrition and general science from Oregon State University.


New York State does not license Naturopathic Physicians to practice medicine. The practice of the profession of medicine is defined as diagnosing, treating, operating or prescribing for any human disease, pain, injury, deformity or physical condition. Donielle Wilson, ND is not an MD and does not practice medicine in the state of New York. Furthermore, her services are not meant to replace or to be a substitute for those of a licensed medical practitioner. If you seek the care of Dr. Wilson in New York, she advises that you seek the concurrent care of a health care provider licensed in New York State.


In New York State Dr. Wilson functions as a health consultant and focuses her practice on the enhancement of health. She uses her education and experience to give you suggestions. You agree to the physical contact necessary for assessment of your case and you make decisions that are right for you about whether to use her suggestions.


In Connecticut Dr. Wilson is a licensed Naturopathic Physician. She is licensed to diagnose and treat, perform physical exams and order labs and imaging. We may discuss substances that have not been subject to double blind clinical studies or FDA approval or regulation. You assume the responsibility for the decision to take any natural remedy. If you feel you are having any adverse reaction then stop taking all supplements immediately. If you are pregnant or nursing, confirm the safety of any supplements with your obstetrician or pediatrician. Recognize that, as an effect of the suggestions provided by Donielle Wilson, ND, the signs and symptoms of your medical condition(s) may diminish or disappear.


I have read and understand the information provided. I agree to the services provided by Donielle Wilson, ND.

Note: This is the agreement we make when we start working together. Please read it over and if you have any questions, feel free to contact us. If you’d like to make an appointment now, please do so by clicking below!

Make an Appointment with Dr. Doni »

Share this Post:
MTHFR Reset 3-week Program
Say Goodbye to HPV 12-week Program
Dr. Doni Social Media
Popular Posts
Recent Podcasts

Signup to receive our weekly newsletter with all the latest news, podcasts and special offers

New Book - Order Today!

Master your Stress Reset your Health

Release. Rebalance. Restore.
Simple Practices for Shifting from your State of Stress to your Flow and Freedom
Master Your Stress, Reset Your Health by Dr. Doni Wilson



Order Now!
More from Dr. Doni

Related Posts

Dr. Doni was interviewed by CanvasRebel, highlighting the entrepreneurial side of her practice. They cover how Dr. Doni built her reputation, the resilience that it takes, and how she got started in her career.

Dr. Doni Wilson Featured in CanvasRebel

Dr. Doni was interviewed by CanvasRebel, highlighting the entrepreneurial side of her practice. They cover how Dr. Doni built her reputation, the resilience that it takes, and how she got started in her career.

We get so accustomed to stress exposure that it becomes just a part of everyday life. We don't even notice it anymore, like a fish and its fishbowl.

Stress Is Like a Fishbowl

Most of us get so accustomed to stress exposure that we can’t imagine what it is like to exist outside of it. Read Dr. Doni’s very personal and vulnerable story about troubling relationships, feeling disconnected from herself, and how she discovered the breakthrough of five stress types.

Vitamins and supplements can help support your body with depleted nutrients, improving your life and longevity.

Vitamins and Supplements: What to Take, How Often, and the Best Pill Organizers

Even when we eat healthy, we might not be getting enough of the vitamins we need. Stress exposure causes our bodies to burn through more nutrients to help us keep up with our daily lives and metabolic needs. Dr. Doni covers the vitamins and other dietary supplements that can help support your body and improve your health and longevity.