I, ________________________________ do hereby give consent to Kelowna Naturopathic Clinic and specifically to Dr. Garrett G. Swetlikoff, N.D. to perform intravenous Ca and/or MgNa2EDTA chelation therapy (“Chelation Therapy”) for the purpose of treatment of atherosclerotic disease and/or heavy metal toxicity, and/or prevention or treatment of degenerative diseases. I understand that Chelation Therapy is a standard therapy widely approved for the treatment of heavy metal toxicity: however, its usage is considered controversial for the generalized treatment of atherosclerotic vascular disease and other degenerative diseases, and the view that it is of benefit in the treatment of such disorders is accepted by a minority of the medial community and is considered “experimental” by most physicians and insurance companies. I am advised that my treating physician believes that Chelation Therapy does have positive clinical benefits. I have been informed that other treatment approaches have been used in these conditions, including but not limited to bypass surgery or angioplasty and these alternatives have been explained to me to my full satisfaction.

I understand that the benefits of Chelation Therapy are much greater if I follow a healthy lifestyle, (non-smoking, weight control, proper exercise, proper diet, and nutritional supplementation). I understand that an initial series of ____ treatments are anticipated, and that these treatments may be extended over a number of months. I have been informed that Chelation Therapy may need to be repeated from time to time in the future in order to maintain the benefits. I understand that it is my option to stop this treatment protocol at any time without incurring any further expense after I have directed that such treatment be stopped.

I have been informed of possible risks and side effects including but not limited to: discomfort at the injection site, thrombophlebitis, hypocalcemia, fatigue, muscle cramps, kidney problems including nephrotoxicity, allergic reaction, congestive heart failure, liver disease, anticoagulation, lowering of blood sugar levels and/or hypoglycemia, mineral loss and generalized complaints.

If I have suffered from any previous kidney disease, I agree to execute a medical release so that all previous identified medical records of mine may be obtained form previous treating physicians, and I have disclosed openly any known previous kidney disorders. I understand that this therapy should not be used if I am pregnant unless I have a severe like-threatening disease. I understand that if I have a history of tuberculosis, Chelation Therapy may reactivate arrested tuberculosis and I agree to inform my physician of any occurrence of this disease. I understand the nature of the proposed procedure and the risks and dangers have been explained to me to my full satisfaction. I have not been asked to discontinue care with any specialist.

While I understand that there have been no warranties, assurances or guarantees of successful treatment made to me, I desire to undergo this treatment after having considered the information contained in this document, the information provided to me through my conversations with my treating physician and through materials provided to me by the office to educate me about the treatment. I acknowledge that I had the opportunity to ask any questions of my physician with respect to the proposed therapy and the procedures to be utilized and all of my questions have been answered to my full satisfaction. I also acknowledge that I have received a copy of this signed, informed consent.

I understand that the Medical Service Plan does not pay for chelation therapy with EDTA for vascular disease and does not pay for laboratory testing after chelation therapy has been instituted. I also understand that there are very few commercial insurance companies that will pay for chelation therapy with EDTA for vascular disease.

Date: _________________________

Patients Name: ________________________________________
Signature

Patients Name: ________________________________________
Printed or Typed

Witness: _____________________________________________

Relative or Representative: _____________________________

Rlationship to the Patient: ______________________________