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!

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