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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 MESOTHERAPY |
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I consent to Dr. David Edwards and/or the staff of Bio Health Center administering Homeopathic-Integrative Mesotherapy. I understand that multiple injections are made subcutaneously of homeopathic, nutritional (orthomolecular) and or pharmaceutical preparations for aesthetic and/or therapeutic effects on the body, including, but not limited to, reducing cellulite deposits, localized body fat deposits, skin wrinkling, baldness, rejuvenation of facial and localized body wrinkled skin, as well as for the following specific medical conditions (please list ____________________________________________). I understand that depending on the specific problem , degree of the problem and the specific area(s) of the body involved, a series of injections is administered every 3 to 14 days for a total of 5 to 15 or more sessions. I understand that the benefits of Mesotherapy are much greater if specific medical recommendations, 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 Mesotherapy are generally mild and may include minor bleeding and/or bruising at the injection sites, temporary mild pain or discomfort, localized redness, swelling, itching and/or irritation, potential secondary infection, brief light-headedness or, rarely, true allergy to nutrients, enzymes and/or pharmaceuticals, if used. I understand that tenderness and bruising may last from one to seven or more days. I understand that the nutritional-orthomolecular substances used are derived from soy and egg and to my knowledge I am not allergic to these. 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 Mesotherapy 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 when Mesotherapy 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 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.
Patient Name (Print):
Date: Patient Signature:
Witness (Print):
Date: Witness Signature:
Name________________________________________ Age_______ Date_______________
Name of Primary Care Physician_________________________________________________
Who referred you to this office?__________________________________________________
Are you allergic to soy, egg or any medication(s) (please list)?__________________________
__________________________________________________________________________
Are you currently being treated for any health or medical condition (please list)?_____________
__________________________________________________________________________
Are you currently taking any prescription drugs (please list)?____________________________
__________________________________________________________________________
To your knowledge, do you have: ______ a heart murmur; ______ easy bleeding; ______
any type of chronic infection?
If yes to any of the above, please provide details: ____________________________________
__________________________________________________________________________
Have you had or do you now have any of the following medical conditions or medical problem(s) of any kind? If so, please discuss them with the physician:
Heart problems______High blood pressure______ Lung Disease_______ Diabetes______
Bleeding disorder________Nerve problems_______ Kidney problems_______ Hepatitis______
Chronic fatigue_______Fibromyalgia______ Endocrine disorder_______ Cancer_________
Blood transfusions_____ Illegal drug use______ HIV/AIDS______ Artery/Vein problems______
If yes to any of the above, please include details or any other medical information you consider relevant, if needed:___________________________________________________________
Are you currently attempting a weight loss program? ________ If yes, what type of program(s) have you or are you using?_____________________________________________________
How long have you had the current problem? ______________________________________
Please indicate area(s) of interest for Mesotherapy by using numbers to indicate which area(s) are of most importance to you:_____ Cellulite (locations?_________________), Skin Wrinkling _________ (face_______, other areas (please list)___________________, Balding _________, Other __________________________________________________________
Do you have any specific questions or concerns regarding the Mesotherapy? __________________________________________________________________________
__________________________________________________________________________
