Women’s Patient Consent Forms

If a Grand Canyon Clinics Staff member directed you to this Patient Form page, then you will need to complete this form prior to your consult or doctor’s visit. You can fill in the online form below, or download our PDF form to fax, or bring to our office.

You can download the PDF version of the Women’s consent form to fax or bring to the office


Please read ALL material in the

Consent and Treatment Form
HIPAA Prvacy Form
and Medical History Form


before ACKNOWLEDGE AND ACCEPTING and signing for all three forms at the bottom of the page.

CONSENT FORM

Consent for Evaluation and Treatment

Form GCC9

I voluntarily authorize Grand Canyon Clinics, its Physicians, Nurse Practitioners, Physician Assistants, Medical Assistants, and associated personnel to evaluate and treat my health concerns. I understand that my treatment may consist of a balanced diet, a regular exercise program, nutritional supplements, intravenous therapies including chelation, injections, instructions in behavior modification techniques and may involve the use of prescription drugs.

1. I have been informed that I may be treated with therapies including, but not limited to the following:

2. Risk of proposed treatments: I understand that any medical treatment may involve risks as well as the proposed benefits. I have been well informed of any such risks of treatment including death, the risks of refusal of treatment, and the treatment alternatives have been explained to my understanding.

3. No Guarantees: I understand that much of my healing success is dependent upon my commitment to following the treatment plans outlined for me by the doctor. Even following the program designed specifically for me may not result in the desired outcome. I also understand that my condition may be lifelong and may require changes in eating habits and permanent changes in behavior to be treated successfully.

4. Information developed as part of evaluation/treatment is confidential but may be released to those parties as required by law such as:

5. Treatment is individualized to specific needs and may result in emotional and physical discomfort through the healing processes.

Nutritional supplementation and Diet counseling including I.V. Nutritional Therapy

Chelation therapy: IV and oral EDTA, DMPS, and Hydrogen Peroxide

Addiction Medicine-detoxification from drugs and alcohol and related services

Weight loss Protocols

Hormone Replacement

Botanical medicine

In medical emergencies involving danger to self or to others;

Upon presentation, or reasonable suspicion of abandonment/neglect or physical/sexual abuse of a child or elder;

a court order;

upon receipt of a properly executed consent form;

and where otherwise legally required

Nothing should be construed here-in that there is a perfect remedy or treatment for those disease states considered terminal or incurable.

Patient’s consent: I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained to me. My questions have been answered to my complete satisfaction. I have been encouraged and have been given all the time I need to read and understand this form.

WARNING: If you have any questions regarding the risks or hazards of the proposed treatment or any questions concerning the proposed treatment or other possible treatments, ask the Physician now before signing this consent form.


Telemedicine Health Care

Form GC14

Grand Canyon Clinic provides telemedicine health care specializing in Program’s Designed for Your Specific Health Needs:

Women’s Health

BHRT

Pre-post menopausal therapies

Thyroid health

Anxiety disorders

Cardio assessment

Weight Loss

Diet programs

HCG programs

Nutrition counseling

Lifestyle exercise programs

No longer do you have to be in the state or country to have an appointment, or maybe you just don’t feel well enough to get out of bed or dressed to leave home. If work is too pressing to leave or you have a meeting you can’t miss, make an appointment and Dr. Chastant can schedule a consultation via Skype.

Not part of the Concierge service? You don’t have to be. We have available appointments we reserve just for you, that will save you money in gas, travel and time away from work. Make an appointment today; let us help you be well.

Healthier Hearts Naturally

Taking care of your heart doesn’t come naturally. As you age your heart faces challenges brought on by factors such as diet, exercise, and genetics. Dr. Chastant is uniquely qualified to help you with preventive measures for taking better care of your heart. Using advanced labs and natural therapies you can turn your cardio health around to keep you heart healthy and happy.

For any medical condition that cannot be managed by Grand Canyon Clinics you will be referred out to the patient’s primary care physician, emergency room, urgent care physician, or another medical specialist. The patient acknowledges that they will follow through with the referral for further medical care.

I the patient have read the above release of liability and understand that my seeking of additional health care should/can be cleared by my primary care physician. I am seeking medical assistance from GCC for additional/alternative/traditional/integrative medical care. If my medical needs are not met either by any recommendation or if I feel I need additional care, I will take responsibility for contacting my primary care physician for additional medical services. I will make my primary care physician aware of my past/current and future intentions for medical treatments, traditional and alternative. I will request the clearance from my primary care physician. I will inform Grand Canyon Clinics if I would like them to become my new primary care physician. I release liability from any Grand Canyon Clinics medical provider/employee/staff/volunteer or instructor for any treatments/care/advice if it has not first been discussed or approved by/with my primary care physician. I understand that it is my responsibility to keep my primary care physician aware/updated on my seeking of additional health care with/and/or/for traditional/alternative//homeopathy/naturopathic/integrative medicine.

GCC does not prescribe Opiates, Benzodiazepines, or other Scheduled Medications for pain, anxiety, or depression in our Telemedicine program.

If you are not in a state that our providers are licensed in, then we are only acting as a health and wellness consultant. We are not diagnosing or treating any medical conditions that you may have.


Informed Consent For Intravenous (IV) Therapy & Chelation

Form GC15

This document is intended to serve as confirmation of informed consent for IV therapy and/or chelation as ordered by Grand Canyon Clinic.

I have informed the physician of any known allergies to drugs or other substances that may be included in the ingredients of my solutions, or of any past reactions to anesthetics.

I have informed the doctor of all current medications and supplements.

I understand that I have the right to be informed during the procedure, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent.

The IV intravenous procedure involves inserting a needle into your vein and infusing over a determined period of time, prescribed nutrients (vitamins, minerals, amino acids) or chelation agents. Chelating agents may be infused for pretreatment testing. Chelation testing helps your physician to develop a chelation treatment plan.

I understand that Intravenous (IV) Therapy & Chelation has not been approved by the FDA and is "experimental" and I release Grand Canyon Clinics from any liability regarding my choice of IV Therapy & Chelation

I understand that risks, benefits and alternatives to IVs or IV/Oral chelation may include but are not limited to:

1. The Risks and potential side effects

Discomfort, bruising, and pain at the site of injection.

Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.

Severe reaction, anaphylaxis, cardiac arrest, or death.

2. The Benefits

Injectables are not affected by stomach or intestinal disease.

Total amount of infusion enters the bloodstream and is available to the tissues.

Higher doses of nutrients can be given by vein than by mouth without intestinal irritation that can accompany doses given by mouth.

IV chelation therapy helps to reduce and eliminate heavy metals.

3. Alternatives to intravenous vitamin therapy are oral supplementation and/or dietary and lifestyle changes. Alternative therapies to intravenous chelation are oral chelation therapy or therapies to improve the natural elimination of metal compounds through nutritional supplementation and tissue cleansing such as constitutional hydrotherapy and colon hydrotherapy.

I am aware that other unforeseeable complications could occur. I do not except the physician(s) to exercise judgment during the course of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered. I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. My signature on this form affirms that I have given my consent to IV therapy with any different or further procedure, which in the opinion of my physician(s) or other(s) associated with this practice, may be indicated.

I understand the information provided on this form and agree to the foregoing. I understand that there is no implied or stated guarantee of success or effectiveness of any treatment. The procedures set forth above have been adequately explained to me by my physician. I understand that I am free to withdraw my consent and to discontinue participation in their treatments at any time. I understand that, except in emergencies, I must give 24 hours notice of intent to cancel or reschedule my appointment. I understand that I will incur the full fee for treatment, regardless of amount used due to wasted materials.

My signature below confirms that:

1. I have received all the information and explanation I desire concerning the procedure.

2. I authorize and consent to the performance of the procedure(s)


PROLOTHERAPY INFORMED CONSENT

Form GC16

This form includes consent for Prolotherapy, PRP and Adipose Stem Cell treatments. Signing this document does not mean that we are actually performing all of these procedures on you, only that we have the consent signed and ready to go should you decide to have any of these procedures done.

PROLOTHERAPY INFORMED CONSENT

I have been advised and consulted about the injection technique of Regenerative Injection Therapy, also known as Prolotherapy.

I have been advised that Prolotherapy is an established treatment technique used to tighten and strengthen weak and damaged ligaments and tendons which are believed to cause pain and instability. It is also used to decrease pain and improve function in some forms of arthritis. The treatment requires the injection of local anesthetic (Procaine or Lidocaine) plus 12-25% Dextrose (sugar water). The sight of injection is where the ligament or tendon attaches to the bone, at the joint capsule or inside the joint, also possibly along the ligament/tendon where injured.

The procedure may initially increase my painful area or reproduce my symptoms for one to three days (potentially as long as ten days) and then may decrease my pain complaints, but may not completely eradicate them. I understand that some insurance companies have determined this treatment to be experimental due to the lack of large research studies in scientific literature.

I understand the BENEFITS of the procedure are improved or resolved pain and improved function.

I have been informed that the ALTERNATIVES to Prolotherapy are:

1. Do Nothing

2. Surgical Intervention may be a possibility

3. Injections with steroids may also be helpful, but usually do not give lasting results.

4. Manipulation and/or Acupuncture may afford temporary relief.

I have been informed that the RISKS/COMPLICATIONS of Prolotherapy are:

1. Immediate pain at the injection site

2. Stiffness at the injections site

3. Bruising/bleeding

4. Headache

5. Allergic reaction to the solution

6. Infection of the joint

7. Injury to nerve and/or muscle

8. Spinal cord injury during back injections

9. Temporary or permanent nerve paralysis

10. There may be no effect from the treatment

11. Pneumothorax (air on the outside of the lung)

12. Itching at the injection site

13. Nausea/vomiting

14. Dizziness or fainting

15. Swelling after joint injections

16. Temporary blood sugar increase

17. Numbness

18. Death from complications of the treatment

I have been informed that the risks of NO injections are:

1. Continued pain & Continued degeneration of the joints adjacent to the ligament.

CONSENT FOR THE USE OF PLATELET RICH PLASMA

I hereby authorize Grand Canyon Clinics and whomever they may designate as his/her assistant, to draw a small sample of autologus blood for the production of Platelet Rich Plasma (PRP) and for it to be used during this procedure as deemed necessary. If any unforeseen condition arises in the course of procedure/s in addition to or different from those now contemplated, I further request and authorize her to do whatever she deems advisable.

Platelet Rich Plasma is composed of platelets and plasma. Platelets are tiny cells that are partially responsible for causing blood to clot. Platelets also contain large reservoirs of natural growth factors. These growth factors are necessary to begin tissue repair and regeneration at the wound site. Growth factors derived from platelets initiate connective tissue healing, bone regeneration and repair, promote development of new blood vessels, and stimulate the wound healing process.

The nature and the purpose of the operation or procedure, possible alternative methods of treatment, the risk involved, and the possibility of complications have been fully explained to me by a physician.

I acknowledge that no guarantee or assurance has been made as to the results that may be obtained.

CONSENT FOR THE USE OF ADIPOSE STEM CELLS

I have been advised and consulted about the injection technique of Adipose Derived Tissue Stromal Vascular Fraction (AD-tSVF). The procedure of fat harvest has been explained to me and I am aware of the risks involved which include:

Infection at the site, abdominal/visceral perforation, bleeding, bruising, itching, swelling and increased pain at the site for several weeks.

I understand that my harvested adipose will be non-altered and only rinsed with saline and emulsified to prepare it for injection. I understand that these are my own cells and they are adult stem cells. My AD-tSVF will then be mixed with my own Platelet Rich Plasma and injected into the sites to be treated on the same day they are harvested.

I acknowledge that no guarantee or assurance has been made as to the results that may be obtained.

HIPAA Privacy Form

HIPAA Privacy Form

Form GCC4

Grand Canyon Clinics, PLLC • 2717 N Fourth St Ste 100 Flagstaff, AZ 86004 • T 480.442.4204

GrandCanyonClinics.com

Created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Grand Canyon Clinics (known as GCC through out this document) Notice of disclosure in how health information about you, as a patient of GCC may be used and disclosed, and how you may access your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

GCC is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information.

Although these laws appear complicated, we must provide you with the following important information:

Regarding the use and disclosure of your health information in certain special circumstances. Please continue to read the circumstances as listed.

To public health authorities and health oversight agencies that are authorized by law to collect information.

Lawsuits and similar proceedings in response to a court or administrative order.

Required to do so by law enforcement official.

If necessary to reduce or prevent a serious threat to your health and the safety or the health and safety of another individual or the Public. Only then would GCC make disclosures to a person or organization able to help prevent the threat.

If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

Federal officials for intelligence and national security activities authorized by law.

Correctional institutions or law enforcement officials, if you are an inmate or under the custody of a law enforcement official.

For Workers Compensation and similar programs.

Your rights regarding your health information

You have the right to request that GCC communicate with you about your health and related issues in a manner or at a certain location. You may ask that we contact you at home, rather than work.

You have the right to request that GCC restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. GCC is not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.

You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including Patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to GCC.

GCC must respond to this request within 30 days.

You may ask GCC to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by GCC. To request an amendment, your request must be made in writing and submitted to GCC.

You are required to provide GCC with a reason that supports your request for amendment.

GCC must respond within 60 days. The Privacy Officer or the patient’s physician will provide this. If the physician believes the information is complete and accurate; the physician can refuse to make any changes.

You are entitled to receive a copy of this Notice of Privacy Practices. You may request GCC to provide you a copy of this Notice at any time.

To obtain a copy of this notice, please contact GCC.

If you believe your privacy rights have been violated, you may file a complaint with GCC or with the Secretary of the Department of Health and Human Services Center. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

GCC will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.

If you have any questions regarding this notice or our health information privacy policies, please contact GCC to discuss.

Medical History FORM