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.