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DAVID A. EDWARDS, MD, H.M.D.
LTD PRACTICE LIMITED TO INTEGRATIVE MEDICINE |
615 Sierra Rose Drive, Suite 3
Reno, NV 89511 (775) 828-4055 Fax (775) 828-4255 |
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INFORMED CONSENT FOR BIO-OXIDATION THERAPY |
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I
hereby give my consent to Dr. David A. Edwards
and the staff of Bio Health Center to administer Bio-Oxidation Therapy,
consisting of oxygen, intravenous hydrogen peroxide or Phosphatidyl Choline
and/or medical ozone alone or in cyclic combination. I have been informed
and under stand that bio-oxidation methods of treatment for athero-arteriosclerotic
vascular and other degenerative diseases are controversial and the view
that it is beneficial for the treatment of such related disorders is accepted
by a minority of physicians in the US I understand that a majority of
US physicians presently consider such treatment as "investigational."
I understand that my treating physician believes that this therapy does
have positive clinical benefit and may be useful in my particular case.
I have been informed about and understand that there may be alternative
treatments for vascular disease, including surgical bypass grafting, angioplasty
and/or pharmaceutical therapy. These alternatives have been explained
to my full and complete satisfaction.I understand that the benefits of bio-oxidation therapy are much greater if a healthy lifestyle, regular exercise, proper diet, avoidance of luxury toxins (tobacco, etc.) and nutritional supplementation are used. I understand that an initial series of daily or weekly treatments is administered, depending on which form of bio-oxidation therapy is used. I have been informed and understand that extremely low doses (in the Homeopathic microgram or thousandths of a milligram range) of hydrogen peroxide and/or ozone are used. I understand that the side effects of such low doses may include pain at the infusion site, local redness or local inflammation of the vein. In addition, ozone can aggravate a high thyroid condition and should NOT be used when such an untreated condition exists. I have been informed that the prescription medication Captopril (Capoten™ Capozide™) should NOT be taken while receiving ozone and if I am currently on this medication my physician will substitute a compatible medication if necessary. I understand that anti-oxidant nutritional supplements including, but not limited to, vitamins A,C,E, beta carotene and the mineral selenium are required during a series of bio-oxidation treatments. I understand that when used in conjunction with chelation therapy, the required supplements for both protocols are to be taken. I understand that laboratory testing to monitor the effects of bio-oxidation therapy including, but not limited to, biological terrain analysis (BTA), will be required before, after and possibly during bio-oxidation treatment. An explanation for the necessary tests has been provided to my satisfaction by my physician. I understand that all costs for testing are separate from and in addition to the cost of chelation therapy. I agree to execute a medical release so all previous medical records from any and all previous treating physician(s) may be obtained as needed.
I understand that, with the exception of oxygen therapy, bio-oxidation therapy is NOT currently FDA approved. Because of this bio-oxidation therapy and laboratory tests related to its use are NOT covered by MEDICARE™ and will usually NOT be covered by private insurance. I also understand that MEDICARE™ and private insurance usually restrict payment for oxygen therapy to what they determine as "medically necessary," and bio-oxidative oxygen therapy is NOT covered by MEDICARE™ and is usually NOT covered by private insurance. Due to these facts I understand that I am responsible for all costs involved with chelation therapy. While I understand that NO warranties, assurances or guarantees of successful treatment have been made to me, I have decided to undergo bio-oxidation treatment after having considered the information contained in this document, the information provided to be by my treating physician and any additional educational/consumer information I have reviewed about bio-oxidation therapy. I acknowledge that I have had ample opportunity to ask any questions of my physician with respect to the proposed bio-oxidation therapy and any and all procedures to be utilized related to it. All of my questions have been answered to my full and complete satisfaction. I have not been asked to discontinue my care with any other physician. I understand the nature of the proposed treatment and the risks and dangers have been explained to me to my full satisfaction. I understand that I will receive a copy of this signed informed consent if I request it.
Patient Name (Print):
Date: Patient Signature:
Witness (Print):
Date: Witness Signature:
