Consent Form |

Please check each box below *

I understand that even the gentlest of therapies can cause complications or side effects. I understand that it is very important that I inform the naturopath of any diseases I have and medications or supplements that I am currently taking to reduce this risk. I understand and am informed that, as in the practice of medicine, in the practice of naturopathy, there are some risks to implementing a new substance, including, but not limited to: * Allergic reaction to supplements, nutritional changes, or herbals.

I do not expect the naturopath to be able to anticipate and explain all risks and complications, and I wish to rely on the naturopath to exercise her best judgment, based upon the facts then known, in my best interests.

I understand that charges are to be paid at the time of the visit unless specific arrangements were made prior to my scheduled appointment.

I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others without my expressed written consent or if required by law. I understand that I may look at my medical record at any time and may request a copy. I understand that information from my record may be analyzed for research purposes and that my identity will be protected and kept confidential.

I understand that results are not guaranteed.

I understand that naturopathy is not regulated in the state of Pennsylvania. While Rose Paisley,ND is licensed as a primary care provider in the state of Oregon, she is not licensed as a physician in the state of Pennsylvania. In this state, Rose Paisley functions as a healthcare consultant.

I understand that any advice given by Rose Paisley is a naturopathic recommendation and not medical advice. Patients requiring a medical or pharmaceutical prescription or a medical diagnosis should seek care elsewhere.

Consent *

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content. By signing below I agree to the above-named procedures. 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 seek treatment. By checking this box you are signing this document and your ip address will be logged upon form submission.

Disclaimer *

I understand that naturopathy is not regulated in the state of Pennsylvania. While Rose Paisley, ND is licensed as a primary care provider in the state of Oregon, she is not licensed as a physician in the state of Pennsylvania. In this state, Rose Paisley functions as a healthcare consultant.

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This information is not a substitute for a medical diagnosis or treatment. Please consult with your physician regarding any health concerns. If this is a medical emergency, call 911. To schedule a consultation or a speaking engagement contact me:

For more information about licensing in Pennsylvania visit www.panp.org

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