CONSENT TO ALTERNATIVE/COMPLEMENTARY THERAPIES PATIENT INFORMATIONLast Name*First Name*MIDate of Birth* SS #*PATIENT INFORMED CONSENT - ALTERNATIVE THERAPIES This office uses a variety of treatment methods in order to care for our patients. Some of the methods used have been classified by various licensing authorities as holistic, complementary or alternative to traditional "Standard of care" therapies (Ohio Revised Code ORC 4731.227) to those provided by allopathic physicians (medical doctors). Examples of treatments offered, if indicated by the physician, include use of supplements (vitamins), nutritional counselling, acupuncture , homeopathy and others. My signature below indicates my knowledge and approval of the use of alternative therapies and that I have been informed about the benefits and dis-benefits of these therapies and the likely outcomes associated with the available treatments for my condition , either traditional or alternative. I have had an opportunity to discuss with my physician the purpose of the use of these therapies and the risks associated with both traditional and alternative therapiesDate* This iframe contains the logic required to handle Ajax powered Gravity Forms.