DAVID A. EDWARDS, MD, H.M.D.
PRACTICE LIMITED TO
615 Sierra Rose Drive, Suite 3
Reno, NV 89511
Fax (775) 828-4255
INFORMED CONSENT FOR INJECTION LIPO-SCULPTING©
I consent to Dr. David Edwards and/or the staff of Bio Health Center administering Homeopathic-Integrative Injection Lipolysis
©. I understand that Lipo-Sculpting© (Injection Lipolysis©)
is intended to produce effects similar to surgical liposuction without anesthesia or invasive surgery risks. I understand that multiple injections are made subcutaneously of homeopathic and nutritional (orthomolecular) preparations for localized"Lipo-Sculpting©
" of various specific and separate areas of excessive body fat accumulation (under eyes, chin, back of the arms, breast fat reduction, "love handles," abdomen, buttocks, thighs and/or around knees) and is used for cosmetic-aesthetic purposes. I understand that depending on the degree of excess fat accumulation to be reduced and the specific area of the body involved, a series of injections is administered every 10 to 14 days for a total of 3 to 10 or more sessions. I understand that the benefits of Homeopathic-Integrative Lipolysis Injection therapy are much greater if regular exercise and fat loss diet are also followed. I understand that additional Homeopathic-Integrative support measures, therapy and/or prescription pharmaceuticals may also be recommended on an individualized basis. I understand that these will be recommended as part of an overall treatment plan. I understand the SIDE EFFECTS
of Injection Lipolysis© are generally mild and may include minor bleeding and/or bruising at the injection sites, temporary mild pain or discomfort, localized redness, itching and/or irritation, potential secondary infection, brief light-headedness or, rarely, true allergy. I understand that tenderness and bruising may last from one to seven or more days. I understand that the nutritional-orthomolecular substance is derived from soy and to my knowledge I am not allergic to soy. I understand that Nevada Revised Statutes (NRS 0.040) define three schools of medical practitioners: "allopathic" (MD), "osteopathic" (DO) and "homeopathic" (HMD), and that they may differ in their approach to diagnosis and/or treatment of disease. I have been informed and understand that due to its Homeopathic, nutrient nature and natural occurrence, the clinical use of Homeopathic Liposculpting© therapy falls under Homeopathy and "Orthomolecular Therapy" as defined in Nevada law (NRS 630A.040) and Nevada Administrative Code (NAC 630A.014(1)(d). I understand that Orthomolecular preparations are over-the-counter nutrient and is generally not covered by any federal entitlement program (Medicare, Medicaid, Champus, etc.)
and most private insurance or pre-paid managed ("HMO-IPA-PPO") care. I understand that "Lipo-Sculpture©" is performed as a cosmetic procedure it is not covered by any private insurance. I understand that I am responsible for all costs involved. I understand that the fee quoted for each injection session includes a volume of up to 10 cc's of solution. Additional solution will increase the fee
. I understand the nature of the proposed treatment and the risks have been explained to my full satisfaction. I have had ample opportunity to ask any questions of my physician with respect to the proposed course of therapy and all questions have been answered to my full satisfaction. I understand that NO warranties, assurances or guarantees
have been made. I understand that I may discontinue treatment at any time.
I HAVE READ, UNDERSTAND AND GIVE MY CONSENT TO THE ABOVE.
Patient Name (Print)______________________________ Date___________________
Witness ________________________________________ Date__________________