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ALTERNATIVE THERAPIES DISCLOSURE & INFORMED CONSENT FOR PATIENTS IN MEDICAL OFFICES: TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended integrative and complementary procedure to be used so that you make an informed decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or withhold your consent to the procedure. NOTICE: Refusal to consent to the integrative and complementary procedure should not affect your right to future care or treatment. I (we) voluntarily request Dr. ________________________ as my physician, and such associates, technical assistants and other health care providers as they may deem necessary, to treat my condition which has been explained to me as: ____________________. I (we) understand that the following integrative and complementary procedure(s) is planned for me and I (we) voluntarily consent and authorize these procedures: ____________________. I (we) understand that no warranty or guarantee has been made to me as to result of care. I (we) realize that just as there may be risks and hazards in continuing my present condition without conventional medical treatment, there are also risks and hazards related to the performance of the integrative and complementary procedure(s) planned for me. I (we) have been given an opportunity to ask questions about my condition, conventional treatment, integrative and complementary treatment, alternative forms of treatment, risks of treatment, risks of nontreatment, procedures to be used, and the risks and hazards involved, and I (we) believe that I (we) have sufficient information to give this informed consent. I (we) certify this form has been fully explained to me, that I (we) have read it or have had it read to me, that the blank spaces have been filled in, and that I (we) understand its contents. ____________________ ______________ (Patient Signature) - - - - (Date) ____________________ ______________ (Witness Signature) - - - - (Date) Source: Texas State Board of Medical Examiners, 1999 (The Texas State Board of Medical Examiners includes this patient consent form as part of its guidelines for integrative and complementary treatments.) |
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