Prolotherapy Consent Form

I, ______________________________________________, have read the patient information sheet regarding prolotherapy. I understand that this procedure is not guaranteed to relieve my pain, partially or totally. I also understand that there are potential complications which include increased pain, permanent numbness, infection, abscess, weakness, spinal headache, pneumothorax (collapse of the lung which may require hospitalization), allergic reactions, dizziness and nausea, and other disability.

I understand that this therapy is not covered by the provincial health insurance plan and that other extended health insurance companies may or may not cover this service. I agree to be responsible for my bill.

I give my permission for Dr. Garrett G. Swetlikoff, N.D. to use this treatment on me.

_____________________________________
Signed

_____________________________________
Date

_____________________________________
Witness

  • Top 10 Winter/Christmas Health Tips Listen here:

  • Join Our Newsletter!

    Daily Wellness Inspiration Straight To Your Inbox.

    Our natural medicine clinic offers a wide array of leading edge services.

    New Posts

    Women’s Health Tidbits
    By Dr. Swetlikoff
    Are Cellphones Dangerous?
    By Dr. Swetlikoff

    Additional Articles

    Intermittent Fasting
    By Dr. Swetlikoff
    Sleep Problems?
    By Dr. Swetlikoff

    Health Tips

    Women’s Health Tidbits

    Woman Carrying Baby at Beach during Sunset

    In most families, the woman is likely to lead in the health decisions for not only herself, but also for her spouse and children.  Women tend to be more proactive and holistic in their attitudes and often see the “big picture” better than men.  A woman’s unique anatomy and physiology makes her prone to many medical circumstances foreign to a man.  Menstrual issues, birth control, fertility, pregnancy, menopause, breast health, gynecological cancers and osteoporosis are just a few examples.  Eating disorders, body shaming and sexual and domestic violence are other gender specific problems that women are forced to confront.

    Other significant health threats that are often overlooked in a woman’s life are as follows:

    Heart disease:  most common cause of death in women, underdiagnosed because the public thinks it’s a man’s disease, often appears silently.

    Depression:  2x as many women suffer with depression than men.

    Autoimmune diseases:  3x as many women suffer with conditions like lupus, rheumatoid arthritis, MS etc. than men.

    Alzheimer’s disease:  higher incidence in women causing progressive neuro-degeneration and dementia.

    Stroke, COPD, Diabetes, and Pneumonia are all other common female ailments.

    At KNC, we strive to assist women of all ages and stages in their lives to achieve wellness, physically and emotionally. Specific tests and strategies are employed to help women, with whatever health challenges present, to find meaningful solutions.  A healthy woman, wife, mother, sister, aunt or grandmother, makes the family and community healthier.  Got questions, give the clinic a call.

    Why Choose Natural Medicine?
    By Youtube
Kelowna Naturopathic Clinic