Sample INFORMED CONSENT Form
(2004) You can use this great informed consent as a model for your own!! Now you have no excuse for implementing this necessary procedure in your office.
Garry F. Gordon, MD,DO,MD(H)
Garry- Permission to use and distribute- absolutely so. Credits not necessary. Much of that came from Gordie and by paying attention to what the Board, ie, Garry, says about informed consent.
Thanks and regards- Charlie
Rhythm of Life® Preventive Medicine
Div. Charles D. Schwengel, DO, MD(H), PC
1215 E. Brown Rd., Suite 2 E Mesa, AZ 85203 E (480) 668-1448
CT- Informed Consent 2004- 001.wpd
Patient Name:
Patient Information for Chelation Therapy and Consent to Treatment
1. Chelation Therapy is Offered under Arizona’s Homeopathic Medical Licensing Laws: I have been informed and understand that: Dr. Charles Schwengel is licensed both as a Homeopathic and Osteopathic Physician in Arizona; Chelation Therapy means using Ethylene Diamine Tetra-acetic Acid (EDTA) intravenously, and that this procedure in its entirety is defined under Arizona laws (A.R.S. Title 32, Chapter 29, Homeopathic Physicians) to be a function of licensed Homeopathic Physicians. I understand and agree that Chelation Therapy at Rhythm of Life® Preventive Medicine is offered and provided exclusively under the generally recognized standards of care as set forth through the Arizona Board of Homeopathic Medical Examiners.
2. Insurance Coverage of Chelation Therapy: Intravenous use of EDTA is currently approved by the Food and Drug Administration (FDA) for the treatment of patients with severe heavy-metal poisoning, abnormally high levels of calcium in the blood and dangerous levels of certain drugs. Many doctors and most insurance companies consider Chelation Therapy “experimental” for any use other than these. Most insurance carriers, including Medicare, routinely deny coverage for Chelation Therapy for less severe, asymptomatic or sub-clinical heavy metal “overload” conditions that may be demonstrated by laboratory evidence alone. This also applies to using Chelation Therapy for any purpose related to prevention of health complications that may arise from even extremely low levels of toxic metals in the body. This specifically includes (but is not limited to) any form of circulatory disease such as anginal chest pains, stroke, peripheral vascular disease, and/or documented arterial disease anywhere in the body.
3. I Have Been Advised, Understand and Agree That:
a. The overall goal of Chelation Therapy is to reduce the total body burden of toxic metal ions;
b. Complete removal of all toxic metal ions and keeping them out may not be a reasonable expectation; the reduction of the total body burden of toxic metals is the major goal of Chelation Therapy.
c. Purpose of Chelation Therapy-SPECIAL NOTE: Although EDTA/Chelation Therapy has been popularly believed to have the effect of “cleaning out” the arteries, it does not do this directly. Most patients’ symptoms improve dramatically, but sometimes repeat testing doesn’t necessarily show reduction of plaque or “clean arteries”. In fact, many patient’s symptoms of reduced circulation may improve or resolve completely, even without removal or even an observable reduction in arterial blockages. This may happen by means of better blood health, such as lowered viscosity (thickness), and other factors that we might not have the means of measuring using today’s technologies.
d. Actual treatments of co-morbid health conditions such as heart and circulatory diseases as well as inflammatory conditions and potential blood clots may be treated by prescription Homeopathic medications and specific nutritional medicine and/or herbal medicine concentrates rather than with allopathic drugs and procedures;
e. Dr. Schwengel will work with me and my other doctor(s) if changes in my regular prescription medications are necessary;
f. Proper nutritional support is a very important part of the Chelation Therapy program, and that my results may be favorably or unfavorably influenced by the choices I make regarding which supplements to use;
g. It is my responsibility to make arrangements for periodic Maintenance Therapy treatments;
h. I have a choice between using the Calcium-EDTA (15 minute) or Magnesium-EDTA (3-hour) treatments. I have been advised that the Calcium EDTA treatments are probably more effective at removing heavy metal ions.
i. There will be a professional fee charged for office visits with the Doctor for purposes other than those related to the Chelation Therapy program;
4. Risks and Possible Complications of Treatment: Although Chelation Therapy is generally a very safe form of treatment, I understand that during a course of Chelation Therapy it is possible that I might experience any of these more common problems. Dr. Schwengel and the Chelation Therapy nursing staff are specially trained to take corrective action if any of these should occur:
Infiltration with temporary discomfort at the IV site
(easily correctable with appropriate nursing care)
Local thrombophlebitis (very rare, and responds to heparin and/or homeopathic medicines in the office)
As with many medications, taking too much too fast may lead to kidney stress and/or damage (extremely rare with modern blood testing, dosage and rate of administration)
The staff at Rhythm of Life® Preventive Medicine and Dr. Schwengel are specially trained to administer Chelation Therapy safely and to take appropriate corrective action if any of the above should occur.
5. “Alternatives” and Other Options to Chelation Therapy: I understand that instead of choosing the “non-traditional therapy” of Preventive Medicine Chelation Therapy treatments, I may elect to be treated by a physician and/or surgeon who practices more conventional medical therapy using such methods and techniques as: prescription drugs; interventional and surgical procedures, other rehabilitation measures such as diet modification and exercise. Also, I may elect to do nothing.
6. Consent to Treatment and Release from Harm: I hereby give consent to Rhythm of Life® Preventive Medicine and to its Medical Director, Dr. Charles Schwengel to administer intravenous Chelation Therapy for the purpose of detoxification of heavy metals; for the possible prevention of complications that may arise as a result of accumulations of toxic metals; as Preventive Medicine; and as part of an overall program of Anti-Aging Therapy,
Furthermore, I understand and agree to hold the Rhythm of Life® Preventive Medicine and Dr. Charles Schwengel harmless and free from liability if I should encounter any adverse event related to the administration of intravenous Chelation Therapy that could incur other additional medical costs.
Patient Signature: ______________________________________________ Date: ____________
Witness: _____________________________________________________ Date: ____________
Medical Director: ______________________________________________ Date: ____________
