Naturopathic Consultation Consent Form

I fully understand that Dr. Nicha Samantarat is a licensed naturopathic doctor in the state of California, USA. However, Thailand does not recognize naturopathic medical licensure and does not recognize naturopathic doctor as a primary care provider, therefore, Dr. Nicha is only able to act as a Naturopathic Consultant in Thailand.

I fully understand that the Naturopathic Consultant I am seeing in this office is not a physician, and I am not consulting for medical, diagnostic, or treatment procedures. The appointments do not involve the diagnosing, prognosticating, treating or prescribing of medicines or the treatment of disease, or any act which will constitute the practice of medicine in this country, for which a license is required. Since the Naturopathic Consultant is not a medical doctor or primary care physician, it is recommended that I continue services with my primary care physician.

I hereby understand, agree, and attest to the following:

1. I fully understand that the Naturopathic Consultant I am seeing in this office is not a physician, and I am not consulting for medical, diagnostic, or treatment procedures. The appointments do not involve the diagnosing, prognosticating, treating or prescribing of medicines or the treatment of disease, or any act which will constitute the practice of medicine in this country, for which a license is required.

2. Since the Naturopathic Consultant is not a medical doctor or primary care physician, it is recommended that I continue services with my primary care physician.

3. The services offered by the Naturopathic Consultant are at all times restricted to helping me gain a better understanding of ‘health’ (not disease), so that I will have greater self-awareness and be able to use a self-care plan for daily living.

4. The wellness plan offered (which may include discussion and or sale of nutritional supplements, nutrition and lifestyle modifications, homeopathic remedies, vitamins, minerals, food grade herbs, and other dietary supplements) pertains to the whole body concept of nutrition rather than addressing a specific ailment or condition.

5. The Naturopathic Consultant does not provide emergency or after-hours care. In the event of an emergency, I will proceed to the nearest emergency room.

6. Laboratory testing may be conducted for screening purposes only and does not constitute a diagnosis of any medical condition. It is my responsibility to follow up with a medical doctor if any of the lab results are abnormal.

7. Women who are pregnant or planning pregnancy must inform their Naturopathic Consultant, as this will likely alter the recommendations that are made.

8. Since they are not prescribing physicians, the Naturopathic Consultants will not be able to advise me to discontinue or change doses of my medications. I am advised to consult with my prescribing physician concerning any modifications of my pharmaceutical medications.

9. Potential benefits of following a wellness plan include health optimization, symptomatic relief, and disease prevention. Potential risks include rare allergic reactions, paradoxical reactions to supplements (example: valerian is a relaxing herb for most people, but it is stimulating in some people), and drug-supplement interactions. Although there is a growing body of information regarding such interactions, I understand that not all drug-supplement interactions are known at this time.

10. There are wide individual differences in response to a wellness plan, and no guarantees are made that I will gain any benefit nor suffer any adverse consequences.

11. While I may experience immediate benefits from the wellness plan, I understand that the most effective results will occur when I make a long-term commitment to rebuild my health, which will likely involve some lifestyle modifications.