RESEARCH PATEINT CONSENT FORM Name* First Last Date of Birth*Date Date Format: MM slash DD slash YYYY Phone*Email* Information Sharing* Yes No As a research patient, I agree to share my case details for training and research purposes. I understand my personal details are kept private. Following Treatment Recommendations* Yes No As a research patient, I agree to follow dietary recommendations and undergo in-clinic treatments as prescribed by my practitioner. Provide Feedback* Yes No As a research patient, I agree to complete any forms, evaluations, and research surveys as requested. Protocol Development* Yes No As a research patient, I understand I will not be charged for my treatment. I also understand that I will be assisting the clinic in developing advanced protocols for difficult cases and there are no guarantees for successful treatment outcomes. Consent* I agree to the terms and conditions of The Allergy Naturopath Research Patient.I have read and understood the above requirements and give my consent to undergo research treatments with The Allergy Naturopath.