_____ Informed consent is the process by which a fully informed person can participate in choices about his or her health. This consent is intended to provide you with information about the practice, the nature of decisions regarding your health, reasonable alternatives to the proposed process, the relevant risks, benefits, and uncertainties related to the alternatives, an assessment of your understanding, and your acceptance of the process. This is an invitation for you to participate in your decisions regarding your health.
Nature of Relationship
_____ Ruckus Wellness providers do not practice primary care and their services are not meant to be a substitute for or replace those of your primary care physician. Ruckus Wellness expects that you will be under the care of a licensed physician and encourages open communication between Ruckus Wellness and your current licensed medical professional. Ruckus Wellness do not handle medical emergencies of any kind and refer clients with such emergencies to 911 or the emergency room of their local hospital.
_____ Ruckus Wellness providers will not discuss with you any in depth impressions and recommendations regarding your current health issues until you have completed the online assessment questionnaire. Discussion of subsequent impressions and recommendations will occur only after we receive your assurance that you understand the situation, understand the risks associated with the decision at hand and you communicate a decision to proceed based on your understanding as demonstrated by signing all appropriate documents which includes but not limited to Consultation Disclaimer and Consent for Consultation. We will also advise you of any significant risk that would affect the judgment of a reasonable patient. You always have the right to refuse any proposed ideas entirely or to certain parts of your body.
_____ You agree to advise Ruckus Wellness regarding your medications, drugs, and aspects of your underlying disease and state of mind that may affect your capacity to make an informed decision. You also agree to advise us if you have ever experienced a fit or fainting, if you have a pacemaker, a bleeding disorder, are taking anti-coagulants, or if you have damaged heart valves or have any other particular risk of infection.
_____ If you are determined to be incapacitated or incompetent to make decisions regarding your health, you agree to provide information regarding a surrogate decision maker who can legally speak for you.
Risks of Self Treatment
_____ Potential risks of self-treatment include allergic reactions, sensitivities, adverse effects to natural supplements, and adjustments to making lifestyle modifications. Although this consent form describes major risks of treatment, other side effects and risks may occur.
_____ You agree to take full responsibility for taking any natural remedy that we suggest and you agree that we are not liable for any adverse effects or complications from such natural remedies. You agree to cease taking all natural remedies upon the onset of any adverse effects. You understand that the supplements and herbs need to be consumed according to the instructions provided orally and in writing. Some supplements and herbs may have an unpleasant taste or smell. You agree to immediately notify us of any unanticipated or unpleasant effects associated with the consumption of the supplements or herbs. You will also notify us if you are or become pregnant or nursing as some supplements and herbs may be inappropriate during pregnancy and/or nursing. You acknowledge that we will be unable to anticipate and explain all possible risks and complications of treatment and you understand that the results are not guaranteed.
_____ You agree that if you have a complaint, you will talk about it with Ruckus Wellness. If we are unable to resolve it informally, we agree to binding arbitration in Minneapolis, Minnesota under the rules of the American Arbitration Association. Reasonable discovery shall be permitted and the prevailing party shall be entitled to attorney’s fees and costs of the arbitration.