Thank you for your interest in working with me as a patient. In my practice I offer an integrative approach to health and wellness focusing on a number of traditional and non-traditional approaches to optimize and support the body’s natural ability to heal itself. I am providing you with the following information so you can make an informed choice about your decision to engage my services. Please read this information carefully and let me know if there is any part you do not understand.
I offer a number of complementary and alternative medicine methods in my practice, including Orthomolecular Medicine, Herbal Medicine, Hormone Replacement, etc., collectively called CAM Methods. You have the option of using individually or collectively any of the approaches I offer as part of our work together. Although the CAM Methods appear to have promising emotional, spiritual, and physical health benefits, they have yet to be fully researched by the Western academic, medical, and psychological communities and therefore, could be considered experimental. By signing this document you understand that the CAM Methods are considered alternative or complementary to the healing arts that are licensed by the State of California. Under Section 2234.1(a) of California’s Business and Professions Code, I can offer you advice regarding CAM Methods and render treatment of CAM Methods, subject to the requirements and restrictions that are described fully therein. If you ever have questions or concerns about the nature of the theories, methods, approaches and/or techniques I use, please feel free to ask me for further resources or references.
Orthomolecular Medicine
The body intuitively wants to heal itself and one of my primary methods is Orthomolecular Medicine, which is preventing and treating disease by providing optimal nutrients natural to the body, such as vitamins, minerals, and amino acids. By supporting the body's biochemical processes and identifying other issues, such as toxin build-up in the body, stress, and hormonal imbalances, I create integrative protocols designed to correct these impediments.
Herbal Medicine
As part of our work together, I may recommend that you take herbs. Herbs are believed to have special healing properties based on their ability to support the optimal functioning of your internal system.
Hormone Replacement
Assuming that we establish a good therapeutic relationship, I am quite optimistic that our work together will lead to an outcome that you would consider positive. However, you understand that the practice of medicine is not an exact science and acknowledge that there are and can be no guarantees as to the accuracy or outcomes of any diagnostic approaches or treatment recommendations that you receive from me. However, we will work together to achieve the best possible results for you. A holistic integrative approach to health and wellness can result in a number of benefits to you, including improving health issues and resolution of the underlying reasons that led you to seek treatment but working toward these benefits requires effort on your part in partnership with me. Integrative health requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. You will have to work both in and out of the treatment sessions. I will ask for your feedback and views on your treatment plan, its progress, and other aspects of the treatment plan and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation.
As with any intervention, there are risks associated with various CAM Methods. While the energy medicine methods I use are gentle and considered non-invasive, it’s possible in our sessions together or on your own between sessions, to experience some physical discomfort or emotional distress after your energies have been stimulated and adjusted. Occasionally, some people have experienced dizziness, nausea, or anxiety as occasional side-effects from energy work. If any technique is uncomfortable or does lead to distress or discomfort, please tell me at once. I will stop immediately and can often provide a technique to rebalance the energies whose stimulation is causing distress or discomfort. After the session I will suggest self-care exercises that may help to stabilize and enhance the work we have done.
Herbs, homeopathic remedies, and nutritional supplements are traditionally considered safe. However, it’s possible to experience an unanticipated or unpleasant effect from the consumption of herbs, homeopathic remedies, and nutritional supplements. You agree to notify me or a member of my staff if you experience any unanticipated or unpleasant effects from consuming herbs, homeopathic remedies, or nutritional supplements. In addition, the use of nutritional supplements, herbs, and homeopathic remedies for patients already using pharmaceutical medication (drugs) is usually safe, but some potentially harmful interactions could occur. For this reason, it is important to keep me fully informed about all medications and nutritional supplements, herbs, and homeopathic remedies you may be taking.
You and I will discuss the risks and benefits of including or foregoing the suggested diagnostic and therapeutic approaches I offer, to enable you to decide to include or forego these approaches in your treatment regimen. You should be aware that some of the diagnostic and treatment option offered:
You understand and agree that it’s not possible to anticipate and explain all possible risks and complications of treatment from the CAM Methods and other therapies I offer. By signing this document you acknowledge that you are relying on me to exercise judgment during the course of treatment which I think at the time, based upon the facts then known, is in your best interest.
I may include the recommendation of dietary supplementation as part of your treatment plan. The quality of supplements found in the general market varies widely due to a lack of stringent testing requirements. As a service to you, we make available quality pharmaceutical grade nutraceuticals. You understand that Intuitive Women’s Wellness has applied a usual and customary markup on these products and that I have a financial interest in this markup. You are under no obligation to purchase nutraceutical supplements at our clinic and the quality of the health care services you are offered will not be affected if you choose to either purchase similar products elsewhere or not to follow the recommendations that you take certain supplements.
You understand that insurance companies may or may not reimburse for the CAM Methods I offer and you agree to make payment in full per my office payment policies.
By signing this document you agree that I have disclosed to you sufficient information to enable you to decide to undergo or forgo any of the approaches and other services I offer. Further by signing this document you are engaging me to provide advice that integrates my knowledge of innovative, emerging, nonstandard, nonconventional, and holistic CAM Methods and other approaches to wellness. You understand that the care I provide is highly specialized and based upon information that may not be widely recognized within the medical profession, or in some cases about which there may be disagreement among qualified medical experts. Care rendered may therefore be seen by some as outside the standard of care or may be considered by your medical insurer or government agencies as medically unnecessary, even though recommendations may nonetheless be therapeutically appropriate and constitute good clinical care. You understand that you are freely choosing to take advantage of my services and would otherwise have the option of using conventional health care services exclusively, provided by another professional health care provider of your choosing. You understand that your consent to the nature of our treatment sessions is given voluntarily, without coercion, and may be withdrawn at any time in the future.
You represent that I have provided you with information concerning conventional treatment options and based upon a good faith prior medical examination there exists reasons for using CAM Methods for either medical issues or for health and well-being. I have described to you my education, experience, and credentials related to the CAM methods I practice. You represent that you’re competent and able to understand the nature and consequences of our proposed treatment sessions. You have read and understand the above disclosure about the services offered by me and you have discussed with me the nature of the services to be provided, including any risks and benefits.
You acknowledge that we have discussed and you understand and agree to my standard office policies and procedures, including but not limited to, office and phone appointments, services and fees, non-face to face medical services and related fees, and case management. By voluntarily signing in the space provided below, you hereby grant the practitioner(s) of the Marin Natural Medicine Clinic to perform examinations and therapeutic services, and discuss modalities and options that are considered necessary or advised for your diagnosis and care. You intend for this Client Informed Consent & Disclosure Statement for Integrative Medicine to cover the entire course of treatment for your present condition and for any future conditions (s) for which you seek treatment.
You knowingly, voluntarily, and intelligently assume all risks involved with using the CAM Methods or other therapies Dr. Daniel recommends. As a result of your assumption of these risks, you agree to release, indemnify, defend, and hold harmless Dr. Daniel and her agents from and against any and all claims which you (or your representatives) may have for any loss, damage, or injury arising out of the adverse reactions to which you have been given notice or which may arise without the negligence of Dr. Chan, or in connection with use of the CAM Methods or other therapies, or arising out of or in connection with any referrals to other practitioners. You further acknowledge that it is your responsibility to inform your primary care physician or any treating physician(s) and other health care providers concerning the therapies you receive from Dr. Daniel so they can determine, within their professional competence, whether any harmful or adverse effects are possible given their treatment of your medical condition(s).
YOU HAVE CAREFULLY READ THIS FORM AND ACKNOWLEDGE THAT YOU UNDERSTAND IT. NO REPRESENTATIONS, STATEMENTS, INDUCEMENTS, ORAL OR WRITTEN, APART FROM THE FOREGOING WRITTEN STATEMENT, HAVE BEEN MADE. This form shall be interpreted under California law, and California will be the forum for any lawsuits filed under or incident to this form. If any portion of this form is held invalid, the rest of the document will be in full force and effect.
By submitting this registration you are agreeing to the terms of this document.