New Patient Form - Dr Dominique Wells

Consent Information

The following consents are for all therapies available at the clinic. These consents are only applicable if you are undertaking these therapies.

General Consent

The staff at IMH Gold Coast may request your previous testing results on behalf of your treating practitioners. These may include, but are not limited to pathology, radiology, and any relevant specialist treatment reports from third party providers.

Some of the accessory functional pathology tests, treatments and products administered by practitioners at IMH Gold Coast may be outside the parameters of conventional medicine in Australia. They include IM, IV and PR applications.

These tests, treatments and products fall into the category of Natural or Complementary Medicine. These functional tests, treatments and products are supported by empirical knowledge and in many cases by research data.

That these tests, treatments and products are safe, are widely and successfully used by Integrative Medical Practitioners in Centres in Australia and overseas, and are only prescribed with utmost care.

Some functional pathology tests and treatments offered at IMH Gold Coast are not covered by Medicare or private health insurance funds.

All IMH Gold Coast practitioners are members and active participants of their respective professional colleges.

I also understand that practitioners benefit either directly or indirectly from tests recommended at this practice.

I am attending IMH Gold Coast of my own free will and consent and exercise my right to discuss and choose any useful and suitable treatment(s) made available to me. Information obtained at the clinic can and may be used de-identified for research and publication.

I understand that there will be private fees applicable that are not rebatable by medicare or insurance for my consultation, supplements or treatments. Consultation fees will be clearly specified to me by my doctor prior to treatment.

I am signing to confirm that I have understood the conditions as set out above and have been made aware of the associated risks with regards to data protection.

Musculoskeletal Medicine

Musculoskeletal medicine is highly specialised discipline of medicine, covering a wide range of skills and techniques. These techniques at times will involve you to have:

• Needles (acupuncture and hypodermic) inserted into your body.
• The substances injected can be autologously derived, vitamin and mineral and oxygen based.
• Specific body positions and postures with detailed examination.
• Undressed down to underwear.
• Performed prescription exercises twice daily for 4 to 5 repetitions.
• To join a group of 2 to 3 people in 1 class.
• At times there may be a need for close physical contact between yourself and the Doctor.

Musculoskeletal Medicine has relatively few complications in skilled hands though there is a chance of feeling sore or worse for up to 2-3 days. This is normal. It is extremely rare for a fracture or a collapsed lung (pneumothorax) to develop due to the medical therapy. It is also rare for any type of infection or neurological complication to develop from the procedure.

If you have any hesitation about the above information, please discuss with us your concerns. Cervical Manipulations are rarely carried out in this practice. If this is necessary it will be further discussed with you and a special test will be carried out to see if this is possible to perform on you. Information obtained at the clinic can and may be used de-identified for research and publication.

Treatments

Doctors may recommend I receive treatments such as intravenous and/or intramuscular Supplement injections. Treatments recommended may include but not limited to PRP, Botox, Fillers, Glucose or Vitamin injections, epidurals, nerve blocks, progenitor cells, excisions of tissues, intravenous infusions and intramuscular injections.

I understand:

• That these treatments may be outside the parameters of conventional medicine in Australia.
• That these treatments are supported by empirical knowledge and by research data
• That these treatments are widely and successfully used by integrative medical practitioners in centres in Australia and overseas, and are only prescribed and administered with utmost care.
• That these treatments are not covered by Medicare and may not be covered by private health insurance funds.
• That these treatments may not be regulated by the Therapeutic Goods Administration (TGA) and that the IMH doctor deems that these treatments are in my best interest.
• Also that the IMH doctor has made me fully aware of any risks associated with these treatments and has provided me with sufficient information to make an informed decision.

Possible Side Effects

• Local anaesthetic complications: nerve damage, nausea, vomiting, disorientation, fitting, loss of blood pressure, high blood pressure, coma, death.
• At times you will not be able to drive home post procedure
• Intramuscular iron injections may cause permanent brown discolouration of the skin
• Extreme allergy from any substance or object penetrating the skin, resulting in itch, hives, asthma, and even death.

The following symptoms can be inclusive but not exclusive to:

• Haemolysis for patients with G6PD deficiency if high dosage given
• Headaches
• Nausea
• Vomiting
• Trembling
• Fatigue
• Mild Dehydration
• Local irritation of veins (eliminated by flushing at end of IV)
• Chest pain
• Shortness of breath or other breathing issues
• Tightness in the throat and chest
• Allergic reaction-type symptoms (breaking out into hives, rashes, swelling up, or excessive itchiness)
• Magnesium and Vitamin C caution in patients with kidney problems
• Heart block
• Low blood pressure
• Confusion
• Upset stomach
• Hypotension
• Diarrhoea
• Increased Amylase
• Pregnancy lactation considerations (ALA0)
• Interaction with medications
• Skin irritation
• Hypoglycaemia

I am agreeing to the prescribed treatment(s) of my own free will and consent and exercise my right to discuss and choose any treatment(s) made available to me.

I also understand the results of these treatments vary between individuals.

Nutrients, Supplements and Other Substances

Some, or all of the nutrients could be at much higher dosages than that which is specified by the recommended daily intakes by NHMRC (National Health and Medical Research Council).

It is important that I take these prescribed supplements as directed by my doctor.

I will return for review of my health at date which is specified by my doctor.

If I fail to attend these reviews then I will no longer take any of the supplements prescribed to me by doctor after the specified review date.

I understand that these supplements are only prescribed for me and are not to be used for anyone else.

I understand that prolonged taking of certain supplements at high dosage without medical supervision could lead to adverse health outcomes such as nerve and thyroid disorders. I will direct any question of concerns to my Doctor during my consultations.

Some of the products are not TGA listed and may need a SASB form willed in on my behalf.

The Pfeiffer / Iodine / Amino Acid Nutritional protocol includes high doses of B6, iodine, lithium, selenium and molybdenum. These doses need to monitored. Please stop the therapy and inform the doctor if you experience any of the following:

• Tingling in hands, feet and tongue
• Metallic tastes in the mouth
• Undue fatigue or agitation
• Worsening of your condition

WHSO Consent Information

In the case of a work-related consultation or service only including but not limited to a pre-employment medical assessment or a Workers Compensation medical assessment:

I hereby authorise the examining or reviewing doctor, to release any information acquired, collated or ascertained as a result of the examination and consultation including a copy of my driver's licence to my employer or prospective employer or their authorised representative in relation to my employment. I further acknowledge that information obtained by my employer about my medical history and condition from any previous medicals or other consultations may be used as part of the current assessment.