Supplements Consent Form

The Whole List Doc Supplements Consent form

What's your name? *

First

Last

What's your date of birth? *

What's your best phone number? *

What e-mail address is best to reach you at? *

Confirm Email

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Informed Consent Regarding Nutritional and Herbal Supplements According to the Federal Food, Drug, and Cosmetic Act, as amended, Section 201(g)(1), the term drug is defined as an “article intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease.” Technically, vitamins, minerals, trace elements, amino acids, herbs, or homeopathic remedies are not classified as drugs. However, these substances can have significant effects on physiology and must be used rationally. In this office, we provide nutritional counseling and make individualized recommendations regarding use of these substances in order to upgrade the quality of foods in a patient’s diet and to supply nutrition to support the physiological and biomechanical processes of the human body. Although these products may also be suggested with a specific therapeutic purpose in mind, their use is chiefly designed to support given aspects of metabolic function. Use of nutritional supplements may be safely recommended for patients already using pharmaceutical medications (drugs), but some potentially harmful interactions may occur. For this reason, it is important to keep all of your healthcare providers fully informed about all medications and nutritional supplements, herbs, or hormones you may be taking. Sale of Nutritional Supplements at The Whole List Doc. You are under no obligation to purchase nutritional supplements at our clinic. As a service to you, we make nutritional supplements available in our office. We purchase these products only from manufacturers who have gained our confidence through considerable research and experience. We determine quality by considering: (1) the quality of science behind the product; (2) the quality of the ingredients themselves; (3) the quality of the manufacturing process; and (4) the synergism among product components. The brands of supplements that we carry in our facility are those that meet our high standards and tend to produce predictable results. While these supplements may come at a higher financial cost than those found on the shelves of pharmacies or health food stores, the value must also include assurance of their purity, quality, bioavailability (ability to be properly absorbed and utilized by the body), and effectiveness. Given the lack of testing requirements for dietary supplements, product quality varies widely. If you have concerns about this issue, please discuss them with our staff. I have read and understand the above statement *

Full Name:

Today's Date *

Signature *

The Whole List Doc Supplements Consent form

Set Up A Complimentary Call To See How We Can Help You.