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DAVID A. EDWARDS, M.D., 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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I
hereby give my consent to Dr. David Edwards
and the staff of Bio Health Center to administer intravenous chelation
therapy ("Chelation Therapy") for the specific purpose of treating
and/or preventing athero-arteriosclerotic degenerative vascular disease,
heavy metal burden and/or the treatment/prevention of other degenerative
diseases. I understand that chelation therapy is FDA approved and is standard
treatment for heavy metal toxicity. I understand that it is "investigational"
when used for any other "off-label" use, but that the off label
use of any FDA approved drug is legal, common and encouraged by the FDA.
I have been informed and understand that the use of chelation therapy
for degenerative vascular disease is 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 the majority of
US physicians presently consider such treatment as "investigational,"
even though it has been published in a major textbook of cardiovascular
therapy as being beneficial (Cardiovascular Drug Therapy, edited by Franz
Messerli, chapter 175, page 1613-17). I understand that Dr. Edwards and
the certified staff of Bio Health Center believe that chelation 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,
EECP and/or pharmaceutical therapy. These alternatives have been explained
to my full and complete satisfaction.I understand that the benefits of chelation 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 thirty (30) treatments is usually administered over 15 weeks (twice weekly). I have been informed and understand that chelation therapy is routinely maintained or repeated periodically in the future to maintain or improve benefit. I understand that certain nutritional supplements are required during the entire series of chelation treatments. These include, but may not be limited to, Bio Health Plus™ multivitamin and mineral supplement, Bio Health™ coenzyme Q10/L-carnitine, Bio Health folic acid/B12/B6™ and DHEA. I understand that additional supplements may be needed on an individualized basis, and these will be explained by Dr. Edwards or the certified staff, if necessary. I understand that in some cases prescription pharmaceuticals, such as high blood pressure medicine, cholesterol lowering drugs, etc. may be recommended. In addition, I understand that homeopathic, bio-oxidative, herbal, acupuncture, neuro-muscular integrative and neural therapies may add additional benefit when used on an individualized basis. I understand that these therapies may be part of my overall treatment plan and will be explained by my physician if necessary. I understand that I may discontinue treatment at any time without incurring further expense after I have notified and directed my physician that I have decided to discontinue treatment.
I have been informed and understand the possible risks and potential side effects including, but not limited to, discomfort at the infusion site, phlebitis (inflammation of vein), allergic reaction, thinning of blood (bruising), mineral loss, congestive heart failure, transient low blood sugar or calcium, muscle cramps, fatigue and/or dizziness. I understand that kidney problems may result from chelation therapy and that laboratory tests of kidney function (blood/urine tests) are required before and regularly during chelation therapy to prevent damage to the kidneys from excessive heavy metal excretion. I have been informed that circulation and possibly heart testing will be done before and periodically after chelation therapy to evaluate the need for treatment and/or to objectively monitor any improvement. I understand that additional tests, including, but not limited to, ECG (EKG), chest x-ray, toxic mineral assessment and blood tests to monitor cholesterol, minerals, kidney function, etc. will be performed. 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 have discussed openly any known kidney disorder. I understand I should not undergo chelation therapy if I am pregnant, or suspect that I may be pregnant. I understand that chelation therapy may reactivate arrested tuberculosis (TB) and I have discussed openly any knowledge of previous TB or exposure. 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 have been informed and understand that chelation therapy and all physician services, laboratory testing and vascular/heart testing associated with chelation therapy and NOT COVERED by MEDICARE™ and MAY NOT QUALIFY FOR COVERAGE 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 this treatment after having considered the information contained in this document, the information provided to be by my treating practitioner and any additional educational/consumer information I have reviewed about chelation therapy. I acknowledge that I have had ample opportunity to ask any questions of my physician with respect to the proposed chelation 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 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:
