Download www.drericmuradov.com 8712 – 149st (780) 482 – 2788

Adult consent & Information disclosure forms
www.drericmuradov.com
8712 – 149st
(780) 482 – 2788
Background: Naturopathic medicine is a system of healthcare that takes a holistic approach to
assessment, diagnosis, and treatment with a focus on prevention, restoration and health maintenance.
Naturopathic medicine is a continually evolving body of knowledge that combines ancient healing
traditions with current scientific advances in health care to treat the root cause of disease. The
Naturopathic approach attempts to remove the cause of disease and stimulate the body’s inherent
healing capacity using gentle therapies.
Initial consultation will be approximately 60 minutes; this will allow you to express all of your health
concerns, and a treatment plan will begin to be formulated. Laboratory testing and physical exam may
be used to aid in diagnosis and treatment.
A custom treatment plan will be discussed in the follow up visit (typically 30-60minutes). Maintenance
visits may be used periodically to monitor progress or adjust treatment.
Modalities: A number of different approaches may be used throughout the course of healing. Primary
treatment modalities include, but are not limited to, diet, lifestyle counselling, clinical nutrition
(primarily via supplementation), botanical medicine, homeopathy, Traditional Chinese Medicine and
acupuncture, intravenous therapy/mesotherapy and physical medicine.
Individual diets and nutritional supplements (eg. vitamins, minerals) are often recommended to
address deficiencies, and treat disease processes.
Botanical medicine is a plant based medicine that involves herbal preparations to assist in recovery
from injury and disease.
Homeopathy is a form of medicine that uses minute doses and sometimes energetic forms of plant,
animal, or mineral origins to stimulate the body’s ability to heal itself. Healing may be on a physical or
emotional level.
Traditional Chinese Medicine includes the use of acupuncture, Eastern herbs and dietary changes to
balance body functions. Acupuncture refers to the insertion of sterilized disposable needles through the
skin into underlying tissues at specific points on the body to balance the body’s healing energy or
provide pain relief to an area. Electrical stimulation of the needles may be used to accelerate healing.
Intravenous therapy (IV) – delivers vitamins, minerals, and other natural substances directly into the
blood to achieve levels not attainable orally.
Mesotherapy – a technique where small injections of natural substances are placed just under the
skin. Used primarily to treat pain as well as for cosmetic enhancement (facial rejuvenation, hair loss,
body contouring) depending on the substances and depths used.
Physical medicine - refers to the use of hands-on techniques such as soft tissue and spinal
manipulation, similar to Chiropractic techniques.
Even the gentlest therapies may cause complications and unexpected reactions in certain physiological
conditions; this depends greatly on individual factors such as age, genetic variation, pre-existing
conditions, medications, environmental sensitivities amongst other factors.
It is very important that you inform Dr.Muradov of any disease process that you are suffering from, any
allergies you have and any medications/over the counter drugs/supplements that you are currently
taking. Please advise immediately if you are pregnant, planning to be pregnant, suspect you are
pregnant, or if you are breast-feeding.
Health risks associated with Naturopathic Medicine include but are not limited to:
 Aggravation of pre-existing symptoms
Allergic reactions to supplements or herbs or injections.
Pain, bruising or injury from injections/blood draws, acupuncture, manual therapy, or cupping
 Fainting or puncturing of an organ with acupuncture needles
Muscle strains and sprains or disc injuries from spinal manipulation
However, Dr.Muradov has been extensively trained in Naturopathic healing and strives to practice
medicine with the greatest regard for patient safety in order to reduce the likelihood adverse
reactions.
Statement of Acknowledgement
I, _________________________ (print name), understand and am informed that, as in the practice of
other medicine, there are some risks to naturopathic therapies, some of which, but not all, are outlined
in this document. Furthermore, as in the practice of other medicine, there is always the potential for
misdiagnosis, missed diagnosis or ineffective treatment and I acknowledge that I do not hold Dr.
Muradov responsible for any of these potential mentioned possibilities. The information I have provided
is complete and inclusive of all health concerns, including the possibility of pregnancy, allergy and all
medications I am taking, including over-the-counter drugs and supplements. I understand that no
guarantee has been made to me as to the result or cures that may be obtained from examination or
treatment in this clinic. I accept full responsibility for any fees incurred during care and understand that
payment is due at the time of service. I acknowledge that Dr. Muradov will be playing an adjunctive role
in my health care and standard screening tests and primary care should still be provided by a licensed
medical doctor.
I also confirm that I have the ability to accept or reject this care of my own free will and choice and that I
am not an agent of any private or public agency attempting to gather information without so stating.
I intend this consent form to cover the entire course of treatment for my present condition and for any
future condition(s) for which I may seek treatment. I understand that I am free to withdraw my consent
and to discontinue participation in these procedures at any time.
Patient Name (please print): _________________________________
Signature of Patient or Guardian: _____________________________
Date: _________________
Collection, Use and Disclosure of Personal Information
Privacy of your personal information is an important part of our clinic, while providing you with quality
naturopathic care. We understand the importance of protecting your personal information. We are
committed to collecting, using and disclosing your personal information responsibly. We will try to be as
open and transparent as possible about the way we handle your personal information. All staff
members who come in contact with your personal information are aware of the sensitive nature of the
information that you have disclosed to us. They are trained in the appropriate use and protection of
your information. Our privacy policy attempts to ensure that only necessary information is collected
about you.
This clinic will collect, use and disclose information about you for the following purposes:
- To assess your health concerns
- To advise you of treatment options
- To provide health care
- To distribute health care information to you
- To book and confirm appointments
- To email you about your care or to inform you
about promotions or lectures at the clinic
- For teaching and publishing purposes on an
anonymous basis
- To communicate with other treating healthcare providers .
- To allow us to efficiently follow-up for
treatment, care and billing which may include
leaving information on a voicemail service.
- To establish and maintain contact with you
- To communicate to a legal guardian or a
significant other or family member if a situation
calls for these individuals to know more about
your health.
- To invoice for goods and services
- To complete claims for insurance purposes
- To process credit card payments
- To collect unpaid accounts
- To comply generally with the law
- To allow potential purchasers, practice brokers
or advisors to conduct an audit in preparation
for a practice sale
By signing the consent section of this form, you have agreed that you have given your informed consent
to the collection, use and/or disclosure of your personal information as outlined above.
I have reviewed the above information that explains how my personal information will be collected and
used, and the steps the clinic is taking to protect my information. I agree that Dr.Eric Muradov can
collect, use and disclose personal information about me as set out above in the information.
Patient Name (please print): _________________________________
Signature of Patient or Guardian: _____________________________
Date: _________________