Treatment Agreement Form

wholesome health function medicine services

Treatment Agreement Form

I understand that Physicians rendering the services at Wholesome Health, LLC, are owners, employees or independent professionals engaged in the private practice of medicine. 1. I acknowledge and understand that during my/my child’s care treatment, it is likely that various types of routine diagnostic and treatment procedures (“Procedures”) may be utilized, which are considered necessary techniques for the ordinary care and treatment of condition(s). 2. While these types of Procedures are routinely performed in hospitals and doctors’ offices without incident, there are certain risks associated with each of these Procedures. 3. The physician or his/her associates or assistants are responsible for providing me with information about the Procedures and for answering all of my questions. It is not possible to enumerate each and every risk for every procedure utilized in modern health care. However, physicians/practitioners who practice medicine at Wholesome Health, LLC, have attempted to identify the most common procedures, their associated risks, and possible alternatives. If I have further questions or concerns regarding these procedures, I agree to ask my/my child’s physician to provide additional information. The Procedures referenced herein may include, but are not limited to, the following: 1. a) Needle sticks, such as shots, injections, or intravenous injections (IV’s). The risks associated with these types of Procedures include, but are not limited to, nerve damage, causing tingling or burning, infection, swelling, bruising, infiltration (fluid leakage into surrounding tissue), skin sloughing, bleeding, clotting, allergic reactions, or paralysis. Alternatives to Needle Sticks (if available) include oral, rectal, nasal, or topical medications (each of which may be less effective) or refusal of treatment. 2. b) Physical test and treatments, such as vital signs, internal body examinations, wound cleansing, wound dressing, range of motion checks, rehabilitation procedures, etc. which may be utilized in conjunction with diagnosis and treatment. The risks associated with these types of procedure include, but are not limited to, reactions to the material(s) used, infection, bleeding, discomfort, muscular-skeletal or internal injuries, nerve damage, paralysis, bruising, worsening of the condition and/or refusal of treatment, no practical alternatives exist. 3. c) Medications/drug therapy, which may be utilized in the care and treatment of patients. The risks associated with these types of procedures include, but are not limited to, food-drug-herbal interactions, allergic reactions, adverse reactions, drug dependency and both long and short-term side effects, which vary from medication to medication. Apart from varying the medication prescribed and/or refusal of treatment, no practical alternatives exist.
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7 N. 4th St Newark, Ohio 43055


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