Ocean Natural Health Soniya Gandhi N.D, BHMS The Sage center

12555 SW 1st St. Call-971-217-6556

Beaverton OR 97005

DECLARATION AND CONSENT TO TREAT

Naturopathic medicine is the system of medicine where diseases are treated by natural medicines. The naturopathic doctor evaluates patient’s physical, mental and emotional well being, does required physical examination, does required diagnostic testing and treats patients with the medicines under the scope of Naturopathic medicine. The medicines and therapies are given to stimulate body’s inherent healing capacity.

It is very important therefore, that you provide information about your diseases, symptoms in detail, any medications or over the counter drugs you are currently taking, your past medical history and family medical history.

This is to acknowledge that I have been informed and I understand that:

  1. I have read all the foregoing information and that I understand that the ultimate responsibilityfor my health is my own.
  2. All treatments offered are within the Naturopathic scope of practice.
  3. Any treatment or advice given to me as a patient is not mutually exclusive from any treatment oradvice that I may receive now, or in the future, from another licensed health care provider.
  4. I am at liberty to seek or continue medical care from a physician or surgeon or other health careprovider.
  5. I accept full responsibility for any fees incurred during care and treatment. I agree to fullydischarge this responsibility at the time of the visit unless prior arrangements have been made.
  6. The medicines given by Dr. Soniya Gandhi might include any of the following:
  7. Homeopathic medicines- pills, liquid doses, topical ointments
  8. Botanical medicine-tinctures, capsules, liquid extract, teas, tablet and supplements
  9. Therapeutic nutrition- Nutritional supplements and dietary guidelines necessary forparticular disease or prevention of disease.
  10. Aromatherapy- Use of essential oils to treat illness or prevent illness
  11. The therapies advised by Dr. Soniya Gandhi might include any of the following
  12. Hydrotherapy
  13. Lifestyle counseling
  14. Physiotherapy
  15. Naturopathic Physical medicine - massage, soft tissue massage, muscle energytechniques and exercisesfor particular disorder
  16. Visual therapy consent: Dr. Soniya Gandhi treats patients to improve eyesight with visual therapy, yoga, eye exercises, and relaxation techniques. She also uses homeopathic medicines to improve vision. She advises on the nutrition and eye health. This doesn’t guarantee that you will have normal vision and therefore, you should see your ophthalmologist, and optometrist as needed.
  17. There are some slight health risks to treatment by Naturopathic medicine. These include but arenot limited to:
  18. Allergic reactions to supplements or herbs.
  19. Slight aggravation of symptoms from Homeopathic medicines and body work.
  20. Inconvenience from lifestyle changes, difficulty in following lifestyle changes.
  21. Potential risk from Naturopathic Physical medicine.
  22. Potential benefits: Restoration of health and relief from pain and symptoms of disease, assistance in injury and disease recovery and prevention of disease or its progression.
  23. Notice to Pregnant Women: All female patients must alert the doctor if they know or suspect that they are pregnant as some of the therapies used could present a risk to the pregnancy.

PLEASE NOTE: There is a 24-hour cancellation policy at the clinic. If you are unable tomake your appointment, please notify the clinic 24-hours in advance to ensure you are notcharged the initial visit fee. ______initial here please

With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by Dr. Soniya Gandhi, the naturopathic physician regarding cure or improvement of my condition.

I intend this consent form to cover the entire course of treatment for my present condition. Iunderstand that I am free to withdraw my consent and to discontinue participation in theseprocedures at any time.

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Please Print Name

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Patient Signature/ Parent/Signature of Guardian Date