Naturopathic Doctor Disclosure Statement and Consent for Treatment (Appendix A)

Naturopathic Doctor Name: ____________________________________________________________________
Business Address & Phone Number: ______________________________________________________________
___________________________________________________________________________________________
The nature of the services the Naturopathic Doctor will be providing:
___________________________________________________________________________________________
___________________________________________________________________________________________
 ___________________________________________________________________________________________
Naturopathic Doctors may be registered in other states.  This Naturopathic Doctor is registered or licensed in the following state(s):_____________________________________________________________________________
Complaints regarding this Naturopathic Doctor must be submitted in writing to the Office of Naturopathic Doctor Registration. To obtain a complaint form, please contact the Division at (303)894-7414 or find more information how to file a complaint at:  http://www.dora.state.co.us/reg_investigations/file_complaint.htm.
Naturopathic Doctors are registered by the state to practice naturopathic medicine under the “Naturopathic Doctor Act.”  They are not permitted to perform the following acts:
•	Prescribe, dispense, administer or inject any prescription medications or devices other than epinephrine for anaphylaxis and barrier contraceptives (not including IUDs).
•	Perform surgical procedures, including surgical procedures using a laser device.  
•	Use general or spinal anesthetics, other than topical anesthetics.
•	Administer ionizing radioactive substances for therapeutic purposes.
•	Treat a child who is less than two years old.
•	Treat a child who is two years of age or older, but less than eight years of age, unless: (1) this form is fully completed and signed; (2) the most recent immunizations schedule recommended by the advisory committee on immunization practices to the centers for disease control and prevention in the federal department of health and human services is provided to the parent or guardian with this form; and (3) a release of information is provided to the parent or guardian requesting permission to exchange information with the child’s licensed pediatric health care provider, if the child has one.  
•	Practice medicine, surgery, or any other form of healing other than Naturopathic Medicine.
•	Practice obstetrics.
•	Perform chiropractic services (spinal adjustments, manipulation, or mobilization).  Physical medicine, as described in § 12-37.3-102(12)(b), C.R.S., is permitted.
•	Recommend the discontinuation or counsel against a course of care, including a prescription drug that was recommended by another health care practitioner licensed in Colorado, unless the Naturopathic Doctor consults with the health care practitioner.

Disclosure Statement (To be completed by the naturopathic doctor) 
1.	I, __________________________________________ (print naturopathic doctor name), am a Naturopathic Doctor registered under Title 12, Article 37.3, of the Colorado Revised Statutes.
2.	I am not a medical doctor or a physician licensed under Title 12, Article 36, of the Colorado Revised Statutes. 
3.	I recommend that the patient named below have a relationship with a licensed physician, or if the patient is a child aged two to seven, with a licensed pediatric health care provider.
4.	If the patient is a child aged two to seven, I recommend that that the child’s parent or guardian follow the immunizations schedule that accompanies this form.
5.	If the patient has a relationship with a licensed physician or pediatric health care provider, I will attempt to develop and maintain a collaborative relationship with the physician or pediatric health care provider. To permit this, the patient (or patient’s parent/guardian if patient is a minor) will need to sign a separate release allowing me to exchange information with the licensed physician or pediatric health care provider. 
_____________________________________________________	________________________________
Naturopathic Doctor Signature 						Date
Acknowledgement and Consent for Treatment (to be completed by the adult patient, or parent/guardian if patient is a minor)
I, __________________________________________ (print adult patient’s name, or if the patient is a minor, the parent or guardian name), acknowledge receipt of the above disclosure statement and give my informed consent for treatment for (circle one) myself or my child, __________________________________________  (print patient’s name) by the  above named naturopathic doctor.
Check one: 
The patient ___ does ___ does not have a relationship with a licensed physician or pediatric health care provider.
Name, address, phone of licensed physician or pediatric health care provider: 
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
_____________________________________________________	________________________________
Signature of Patient/Parent or Guardian					Date

(This form must be completed and signed prior to the initial examination of the patient.. If this form is altered, the form provided to the patient must contain all of the information detailed in this form, and comply with §§ 12-37.3-105(2)(f), (3)(b), and 12-37.3-111, C.R.S., and all other laws applicable to Naturopathic Doctors.)