Informed Consent for Osteopathic Diagnosis and Osteopathic Manipulative Treatment (OMT), Medical Acupuncture, and other Treatment at the Clinic
I consent to allow the Danto Osteopathic, LLC providers, as well as their rotating residents and students, to perform necessary medical examinations, osteopathic physical examination, and tests to diagnose and treat my health conditions. I understand that these consents are valid until I revoke them in writing.
Informed Consent for Osteopathic Manipulative Treatment (OMT)
I understand and consent to allow the Danto Osteopathic, LLC providers, as well as their rotating residents and students, to perform osteopathic manipulative treatment (OMT). I understand that OMT is a non-invasive hands-on treatment where my physician or a supervised medical student or resident will position my body in such a way that will result in the alleviation of the physical findings that indicated my need for the OMT.
I understand and consent to OMT in the cervical area knowing that the estimated risk of adverse outcome is 1 in 400,000 to 1 in 3.85 million manipulations. The most significant risk in this area is a vertebrobasilar accident (VBA). The risk factors for such an event include elevated blood pressure, vascular disease, tobacco abuse, 39 years old (+/- 12 years), family history of vascular disease, and history of stroke. If I experience nausea or dizziness during manipulation of my head or neck, I agree to inform my provider. I understand that diagnosis early of vertebrobasilar disease leads to early treatment and better outcomes.
Contraindications to OMT
I understand that OMT may be contraindicated with the following conditions, and I will communicate to my provider if I have any of them: Severe Injury (fractures or open wounds), Infection, or Neoplasm in Area of the OMT; Blood clots in the area of the OMT; Coagulopathy, and Tissue Weakness in an area of OMT (like an aortic aneurysm or a recent surgery).
Informed Consent for Medical Acupuncture
I understand and consent to allow the Danto Osteopathic, LLC providers, as well as their rotating residents and students, to perform medical acupuncture. I understand that acupuncture is minimally invasive in that it does involve a very fine needle penetrating the natural barrier that is my skin. In preparation for an acupuncture treatment, I understand that it is best for me to come to the clinic having practiced good hygiene and being both clean and wearing clean clothes. An alcohol prep pad will be used to cleanse the area prior to the needle being coaxed through my skin. I understand that the acupuncture needles are single-use, disposable, and sterile. Additionally, unlike needles used to inject medications or draw blood, these needles are not hollow and are extremely thin contributing to their near painless insertion as well as them being an unlikely conduit for infection.
I understand and consent to medical acupuncture knowing that there are adverse events despite every precaution being taken. Possible adverse events may include infection, pneumothorax, or nerve injury. In a systematic review of adverse events related to acupuncture during a period of 11 years and across 25 countries there were about 300 reported adverse events. This means that, on average, there were less than 30 events/year and this probably included millions of treatments.
Post-Treatment Discomfort & Instructions
I understand that most musculoskeletal treatments are well-tolerated. I understand that despite musculoskeletal treatment being well tolerated, there may be some discomfort after the OMT, acupuncture, acupressure, trigger point injection, or even cold laser therapy. I understand that this discomfort may feel like a lower severity exacerbation of my pain, and this should dissipate significantly after 24-hours. Additionally, I understand the discomfort experienced may seem like post-exercise discomfort. In either of these instances, I understand that over-the-counter medications, rest, and good hydration (1-2 liters of water) are recommended during the 24-hours after the office visit. I understand that walking and light stretching are recommended for the 1-4 days after the office visit as my body adjusts to the effects of the musculoskeletal treatment. I also understand that vigorous exercise and participating in activities that exacerbate my pains are not recommended for at least 4 days, and that my provider may recommend other more specific recommendations tailored to my uniqueness as an individual.
Right to Refuse OMT, Medical Acupuncture or any other Treatment
I understand that I may refuse OMT, Medical Acupuncture, or any other treatment offered at the Danto Osteopathic Clinic. Additionally, I have the right to discuss any treatment with my provider and I am encouraged to ask questions about my concerns.
Right to a Chaperone
I have the right to have a chaperone present when I am with my provider or any member of the staff. A chaperone is required for any sensitive examination unless I decline in writing. If I am consenting on behalf of a child under 11 years of age, I may serve as the chaperone.
Closed-Circuit Recorded Video
I understand that a closed-circuit video recording will be made and maintained for 2-months after the visit. The visit is recorded for medicolegal reasons to protect myself and that of the clinicians and staff of the Danto Osteopathic, LLC. I understand that I may ask for the camera to be covered during a visit or for any portion of the visit, as when changing into a patient gown for medical acupuncture or another procedure.
Consent for Additional Testing or Treatments not in this Document
I understand that if additional testing or invasive procedures are needed (a joint injection, for example), I will be asked to read and sign additional consent forms.
Telehealth Informed Consent
Telehealth is an optional service that may be provided when in person care is not possible and is requested by the patient. It may involve either telephone or video discussion with a provider.
I agree to participate as a consumer of the Danto Osteopathic Clinic’s telehealth delivery system. I understand that I will be receiving health services through interactive telephone or videoconferencing. I understand the use of telehealth services is an alternative method of health care delivery and that my physician will not be physically in the same room with me.
I understand that although the Danto Osteopathic Clinic and its providers make every effort to protect my privacy by a secure server, they cannot guarantee the security of any information I transmit to them over the internet. By using telehealth services, I recognize that transmissions over the internet are at my own risk and that third parties may unlawfully intercept or access the transmissions. I also understand that despite reasonable efforts on the part of the Danto Osteopathic Clinic, there are risks and consequences in using telehealth services. The risks include, but are not limited to, the possibility that the transmission of sessions could be disrupted or distorted by technical failures. In case of technical failures, my physician will make every effort to re-connect with me.
I also understand that telehealth services are not as complete as services provided via face-to-face, although, several benefits of telehealth services have been identified including increased access to specialized services in remote areas, lower healthcare costs, reduced travel, minimizing time off work, and decreased waiting time for services. I have also been notified that if Dr. Danto believes I would be better served by another form of services (e.g., face-to-face services), I will be referred to an office where such services may be provided. Finally, I understand that there are potential risks and benefits associated with any form of health service and that, despite my efforts and the efforts of the Danto Osteopathic Clinic, my condition may not improve and in some cases may worsen. I understand that my participation in telehealth is voluntary, and I may decide to terminate my treatment at any time. My privacy and confidentiality will be protected.
I understand that there will be no recordings of my telehealth sessions. I also agree to not record my own telehealth sessions without my physician’s knowledge or permission.
I understand that the telehealth services may be billed to participating insurance carriers, but ultimately, I am responsible for reimbursement of any services rendered by the physicians or staff at the Danto Osteopathic Clinic.
I give my consent to receive health services through the telehealth system. I also understand that the services I receive will become part of record my at the Danto Osteopathic Clinic.