Patient Information

Consent for Treatment

I hereby give my consent for treatment for myself, or the named patient (of whom I am the parent or legal guardian who has the right to consent to treatment for the named patient) to Winooski Integrative Medicine PC. Treatment may include health screenings (including behavioral health, drug and alcohol screening), laboratory and imaging studies, diet and lifestyle therapies, nutritional counseling, therapeutic use of nutrients, botanical medicine, acupuncture with or without electrical stimulation, diagnostic ultrasound, naturopathic manipulative therapy, prescription medications, or minor office procedures.

Naturopathic Manipulative Therapy (NMT): I understand that a minority of patients may notice stiffness or soreness after the first few days of treatment. I understand that the risk of more severe complications due to joint manipulation have been described as “rare”, having been estimated at one in one million, and is even further reduced by the use of screening procedures as used by WIM. With this consideration, I understand and am informed that, as in the practice of medicine, in the practice of NMT, there are some risks to treatment, including but not limited to dislocations, strains and sprains, fractures, disc injuries, or strokes.

Photography may be utilized to record my condition with my permission. Photography of my condition may also be used to illustrate a patient’s condition or an aspect of treatment for educational purposes. I understand that photographs form a part of my medical records and are protected in the same way as any other medical recordand if used for medical illustration, my privacy will be protected.

I do not expect my WIM provider to be able to anticipate and explain all risks and complications of treatment, and I wish to rely on them to exercise judgment during the course of treatment, which the doctor thinks at the time is in my best interest based upon the facts then known.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content and to discuss with my WIM doctor the nature, purpose, risks, and benefits of treatments provided. I understand that not all of the above-named services may be utilized for my treatment. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. I understand that results are not guaranteed. I hereby request and consent to the treatment and use of the procedures listed above on me (or on the patient named below, for whom I am legally responsible).

I acknowledge that Winooski Integrative Medicine PC (WIM). has provided me with a copy of its Notice of Privacy Practices that describes how medical information about me may be used and s, and how I can access this information. I understand that if I have questions or complaints, I may contact WIM. I also understand that I am entitled to receive updates upon request if WIM amends or changes its Notice of Privacy Practices in a material way.

Consent to Release of Health Information

I consent to the use within WIM and the disclosure to persons or organizations outside of WIM of my (or of the named patient for whom I am the parent or legal guardian) medical, dental, drug and alcohol, mental health, psychiatry and other treatment and health records (“health information”) by WIM for the following purposes:

1. Use of health information by or for WIM for treatment, payment, and health care operations:
   • Treatment provided by WIM staff.
   • Conducting health care operations of WIM, including financial or quality assurance audits and/ or training.
2. Payment for services provided by WIM. WIM is authorized to obtain payment for health care services and can provide health information to insurance companies, workers’ compensation insurers, or other agencies that pay for health services, as identified in my WIM registration form or other updated insurance information on file with WIM.

Disclosure of health information to persons or organizations outside of WIM for treatment purposes: WIM is authorized to provide all necessary health information as determined by WIM, including information about treatment for substance use disorders, to providers or facilities that I have been referred to, including but not limited to:

• Hospitals for all specialties, in- and out-patient services: University of Vermont Medical Center (UVMMC), Copley Hospital, Porter Hospital, Northwestern Medical Center, Central Vermont Medical Center (CVCA), Dartmouth Hitchcock Medical Center (DHMC).
• Allergy: Timberlane Allergy & Asthma Associates
• Audiology: Adirondack Audiology Associates
• Cardiology: Champlain Valley Cardiology Associates
• Chiropractors: all chiropractors within Vermont
• Dermatology: Dorset St. Dermatology, Four Seasons Dermatology
• Gastroenterology: VT Gastroenterology, Northwestern Medical Center
• Neurology: DHMC Neurology, Neurological Associates of Burlington
• OB/GYN: Lake Champlain Gynecology, Maitri, VT Gynecology
• Ortho: Mansfield Ortho
• Radiology: VT Open MRI, Plattsburg Advanced Imaging
• Veterans Administration Programs and Facilities
• Physical Therapists: All physical therapists within Vermont.