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.

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Signed

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Date

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    Sleep Problems?

     

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    1. Quality Sleep: According to Stats Canada, about 1/3 of the population do not get the recommended 7-9 hours of sleep per day. Many more, get poor quality sleep in the form of falling asleep and maintaining sleep issues. Inadequate sleep, alters the body’s homeostatic circadian rhythms negatively and disallows the body to rest, recuperate, repair and detoxify, both body and brain.
    Poor sleep increases risks to heart disease, stroke, diabetes,obesity, depression, dementia, chronic pain, decreased sex drive and premature aging, not to mention just being tired, grouchy and less productive.
    The more you work, shift work, increased stress and decreased exercise, all worsen sleep quality. On the other hand, good quality sleep increases productivity, athletic performance, learning and  mood.

    At KNC, we can measure sleep and stress hormones, evaluate sleep environment and look at all factors that may be interfering with your sleep pattern. Give us a call.

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