INFORMED CONSENT

By joining this class, you consent to cleansing as overseen by Dr. Erica Zelfand / Natura Family Medicine, LLC, and other practitioners that are associated with or serve as backup for this practitioner, whether or not their names are listed here.

Unless you are already an established patient, doing this cleanse does NOT mean that Dr. Zelfand is your healthcare provider. If you wish to become a patient, please notify the office and a new patient appointment will be scheduled for you to establish care.

Procedures and Treatments

Dr. Zelfand’s cleansing protocols may include:

• Education on general health tips, physiology, and nutrition
• Supplements, such as protein powders, vitamins, herbs, homeopathic remedies
• Lifestyle and hygiene counseling: diet therapy, exercise, sleep, stress management, etc.
• Hydrotherapy: heated and cooled water to stimulate circulation and immune response

By joining this class, you consent to the above procedures and treatments. You also understand that cure or improvement are not guaranteed.

Potential Risks

There are some rare but potential risks associated with cleansing. Some of these risks include, but are not limited to the following:

• Reactions to recommended foods or substances: allergic reaction, side effects, or exacerbation of symptoms
• Inconvenience of lifestyle changes or financial investment
• Emotional release, emotional distress, healing crisis
• Headaches and irritability associated with withdrawal from caffeine, sugar, other substances
• Exacerbation of pre-existing acute or chronic kidney, liver, heart disease, or other conditions which could potentially result in illness, hospitalization, or death.
• Exacerbation of pre-existing blood sugar imbalances, including hypoglycemia on days of reduced caloric intake (if included in this protocol). Diabetic patients may also need to alter their medication/insulin doses during this protocol. This type of medication management is beyond the scope of a class detox, and must be overseen by the prescribing physician.
• Notice to women: All female patients must alert the doctor if they know or suspect that they are pregnant. (This is not a contraindication, but the doctor still needs to know.)

By joining this class, you understand that there are some rare but potential risks to cleansing, including but not limited to those listed above.

You are always welcome to ask about risks and benefits of the proposed therapies at any time. You are also free to skips parts of the class or to discontinue participation in cleansing at any time.

 You are strongly encouraged to check in with your primary care physician (PCP) before doing this cleanse.

COMMUNICATIONS

Because of the nature of the class, Dr. Zelfand or her staff cannot address personal e-mails or phone calls. A private Facebook page will be created for cleanse participants. Questions and comments may be addressed publicly to the doctor or to the group there.

Class attendees will be automatically added to our blog/events listserv. You are free to unsubscribe at any time.

CONFIDENTIALITY

While utmost care is given to protecting your privacy and confidentiality, you are agreeing to certain privacy risks by choosing to engage in a group program.

You will have the option to share private health information with other group members and group facilitator(s), but are under no obligation to do so. Other group members have the option to share their own private health information as well. By joining us, you agree keep any and all disclosures confidential. Do not share information with anyone else outside of group, as this would be a violation of confidentiality.

By joining our group, you also agree not hold Dr. Erica Zelfand for breeches of confidentiality caused by other consenting group members.

By joining the group, you also agree to use all materials sent to you for personal use only. This means not forwarding, distributing, posting, or otherwise sharing the class materials with anybody who is not also enrolled in the course (unless they are your physician).

FINANCIAL POLICY

Payment

Payment for cleansing (whether or not you have insurance) is due in full before the first session. Payment for supplements is due when they are ordered. Returned checks will incur a $35 NSF fee. We will NOT bill your health insurance for your cleanse or provide superbills, as this is an online program and it is not healthcare.

Refunds

There are NO refunds for cancellations.

If due to practitioner illness the series is cancelled, you will be credited the amount to use toward a future class or office visit.

CONSENT

You have had the opportunity to read this form, accept the risks mentioned, and by joining this cleanse series hereby consent and agree to the entire course of Dr. Zelfand’s / Natura Family Medicine’s program.

You agree to release Dr. Erica Zelfand, Natura Family Medicine, LLC, and associates/substitute practitioners from liability should you experience inconvenience, illness, injury, death, or worsening of health ailments while undergoing this cleanse/detox program.

You agree to let your primary care physician know that you are participating in this program. Personalized medical advice will not be provided during this cleanse.