Naturopathic Doctor and Acupuncture Disclosure Statement Consent for Treatment, Request for Collaboration Privacy Practices Dr. Colleen Gagliardi, ND Lac, Dr. Tracy Robinson, ND 5400 Ward Rd, Bldg 1, Ste 100 720-432-5376 Arvada, CO 80002 Patient Information Naturopathic Medicine: The nature of the services the Naturopathic Doctor will be providing: Naturopathic Care which may include the following: History taking, physical examination, laboratory testing, herbal medicines, homeopathic medicine, naturopathic physical medicine, hydrotherapy, supplement recommendations, dietary and lifestyle recommendations. Naturopathic Doctors may be registered in other states. Dr Colleen Gagliardi is registered or licensed in the state of Montana and Colorado. Dr Tracy Robinson is registered in the state of Colorado. We would love to know ways we can improve your care and experience and would love your feedback at the office at 720-432-5376, but also complaints regarding a Naturopathic Doctor may be submitted in writing to the Office of Naturopathic Doctor Registration. To obtain a complaint form, please contact the Division at (303)894-7414 or find more information how to file a complaint at: http://www.dora.state.co.us/reg_investigations/file_complaint.htm. Naturopathic Doctors are registered by the state of Colorado to practice naturopathic medicine under the Naturopathic Doctor Act. They are not permitted to perform the following acts: Prescribe, dispense, administer or inject any prescription medications or devices other than epinephrine for anaphylaxis and barrier contraceptives (not including IUDs). Perform surgical procedures, including surgical procedures using a laser device. Use general or spinal anesthetics, other than topical anesthetics. Administer ionizing radioactive substances for therapeutic purposes. Treat a child who is less than two years old. Treat a child who is two years of age or older, but less than eight years of age, unless: (1) this form is fully completed and signed; (2) the most recent immunizations schedule recommended by the advisory committee on immunization practices to the centers for disease control and prevention in the federal department of health and human services is provided to the parent or guardian with this form; and (3) a release of information is provided to the parent or guardian requesting permission to exchange information with the child s licensed pediatric health care provider, if the child has one. Practice medicine, surgery, or any other form of healing other than Naturopathic Medicine. Practice obstetrics. Perform chiropractic services (spinal adjustments, manipulation, or mobilization). Physical medicine, as described in 12-37.3-102(12)(b), C.R.S., is permitted. Recommend the discontinuation or counsel against a course of care, including a prescription drug that Was recommended by another health care practitioner licensed in Colorado, unless the Naturopathic Doctor consults with the health care practitioner. Disclosure Statement (completed by the naturopathic doctors Colleen Galiardi and Tracy Robinson) 1. Colleen Gagliardi and Tracy Robinson: I am a Naturopathic Doctor registered under Title 12, Article 37.3, of the Colorado Revised Statutes.
2. I am not a medical doctor or a physician licensed under Title 12, Article 36, of the Colorado Revised Statutes. 3. I recommend that the patient named below have a relationship with a licensed physician, or if the patient is a child aged two to seven, with a licensed pediatric health care provider. 4. If the patient is a child aged two to seven, I recommend that that the child s parent or guardian follow the immunizations schedule that accompanies this form. 5. If the patient has a relationship with a licensed physician or pediatric health care provider, at the patient s request, I will attempt to develop and maintain a collaborative relationship with the physician or pediatric health care provider. To permit this, the patient (or patient s parent/guardian if patient is a minor) will need to sign a separate release allowing me to exchange information with the licensed physician or pediatric health care provider. (see below for signature page) Acupuncture Disclosure: Dr. Colleen Gagliardi, ND LAc Education/Credentials: MS Traditional Chinese Medicine, Colorado School of Traditional Chinese Medicine, 2008-2011 Diplomate in Acupuncture awarded by NCCAOM, 2011 Clean Needle Technique Certification through CCAOM, 2011 Environmental Medicine coursework through Dr. Walter Crinnion, ND, Tempe, AZ, 2007 Doctor of Naturopathic Medicine, Bastyr University, 2000-2004 Massage Therapy Certification - Brenneke/Bastyr Massage Intensive, 2002 BS in Business Management, Niagara University, Niagara Falls, NY, 1977-1979 AAS in Business Management, NCCC, Sanborn, NY, 1975-1977 Clinical Employment: Naturopathic Doctor; Colleen Gagliardi, ND LLC; Westminster and Littleton, CO; 2012-Present Naturopathic Doctor; Colleen Gagliardi, ND LLC; Whole Health Center, Highlands Ranch, CO 2010-2013 Naturopathic Doctor; Colleen Gagliardi, ND LLC; Family Health Care Center, Arvada, CO 2009 2012 Naturopathic Doctor; Medicine Root Natural Health Clinic; Miles City, MT; 4/07-6/08 Naturopathic Doctor; Yellowstone Naturopathic Clinic: Billings, MT; 2006-2007 Naturopathic Resident; Yellowstone Naturopathic Clinic/Bastyr University; 2004-2006 Licenses: Massage Therapist Dept. of Health State of Washington Naturopathic Doctor Board of Alternative Health Care, State of Montana License #84 - since 2004 Certified Massage Therapist Dept. of Regulatory Agencies, State of Colorado - #8276 - since 2009 Licensed Acupuncturist Dept. of Regulatory Agencies, State of Colorado - #1757 since 2012 None of these licenses, certificates or registrations have ever been suspended or revoked. Memberships: AANP - American Association of Naturopathic Physicians Patient Information on Acupuncture: Dr. Gagliardi s training as defined by traditional oriental medical concepts includes acupuncture, Chinese herbal medicine, tui na, electro-acupuncture, moxibustion, cupping, gua sha, auriculotherapy, Chinese medicine dietary and lifestyle recommendations, as well as Naturopathic modalities including: western herbal therapy, massage therapy, cranio-sacral therapy, homeopathy, clinical nutrition, lifestyle recommendations, naturopathic physical medicine, including hydrotherapy; and nutriceuticals. Dr. Gagliardi has also had additional training in acutonics and mind/body medicine.
Dr. Gagliardi complies with the rules and regulations promulgated by the Colorado Department of Public Health and Environment, including the proper cleaning and sterilization of needles and the sanitation of acupuncture offices. Only single-use, disposable, factory-sterilized needles are utilized Treatment: Acupuncture has been explained to me as a treatment consisting of the insertion of needles through the skin at specific points on the surface of the body (small amounts of electrical current may be applied to the needles). The purpose of acupuncture has been explained as the alleviation of symptoms or disorders. I understand that complications may result from an acupuncture treatment. Among these possible complications are: areas of anesthesia (numbness), fainting, weakness, nausea, hematoma (bruising), infection, pain and discomfort, pneumothorax, and aggravation of present symptoms. Being tired, hungry or stressed can on occasion make the body more sensitive to the acupuncture treatment. Please tell your provider if you have any conditions that may inhibit blood clotting, such as hemophilia, or medications that cause blood thinning such as Coumadin or Warfarin. Please use caution when walking with bare feet in the treatment room. Acupuncture, acupressure, Moxa, cupping therapy, gua sha therapy, auricular therapy or herbal counseling are considered experimental procedures and are not considered a substitute for Western medicine. Therapies and recommendations offered shall not be construed by the client to be a diagnosis of treatment of any disease or injury. We recommend that you consult your physician for any serious conditions and receive at least two medical opinions. It is your right and responsibility for your own body. I further understand and agree to hold harmless, to indemnify and protect against court action the individual therapist as well as the management and owners of this clinic, in the event of accidental injury on these premises. Patient s Rights: The patient is entitled to receive information about the methods of therapy, the techniques used and the duration of therapy, if known. The patient may seek a second opinion from another healthcare professional or may terminate therapy at any time. In a professional relationship, sexual intimacy is never appropriate and should be reported to the Director of Registrations in the Department of Regulatory Agencies. The practice of acupuncture is regulated by the Colorado Dept. of Regulatory Agencies. If you have any comments, questions, or complaints, contact the Director of Registrations, Acupuncture Licensure, 1560 Broadway, Suite 1350, Denver, CO 80202. Telephone: (303) 894-7800.
Treatment Consent I have chosen to have the doctors at Firefly Natural Health of Colorado treat me using naturopathic modalities. I understand the risk(s) of the treatment(s) and was given the opportunity to ask questions. I understand and accept the risk(s) of the treatment(s). I am aware that Osteopathic (DO) and Allopathic (MD) medical services are available for me to select as treatment options for my medical condition. I understand that the State of Colorado recommends but does not require that I have a primary care doctor separate from the Naturopathic Doctors at Firefly Natural Health of Colorado and that Firefly Natural Health is ready to collaborate with any of my other health care providers upon my approval. I agree to be treated by the Naturopathic Doctors here. I understand that though many states license Naturopathic Doctors, Colorado does not provide an opportunity for licensing of medically trained Naturopathic Doctors but does have a state registration process. I am willing to partake in the treatment created for me by the Naturopathic Doctors here. I also understand that I can exercise my ability to seek medical services from any health care provider that I choose. I understand that the Naturopathic Doctors at Firefly Natural Health are medically and clinically trained in family medicine and natural treatment modalities. I understand that the Naturopathic Doctors are not Osteopathic (DO) or Allopathic (MD) physicians and they do not represent themselves as such. I understand that the Naturopathic Doctors here hold current Naturopathic medical licenses in other states, some with prescribing privileges. I understand that I will not receive any prescriptions for prescription medications from the Naturopathic doctors here as it is not currently in their scope of practice in Colorado. As part of the health care and consulting process, a Naturopathic Doctor may provide comparative risks and benefits of any proposed treatments offered by other health care providers but will not recommend against conventional care. I acknowledge that it is my decision to choose which path of health care to undertake, and that I have the right to follow-up with any health care provider that I choose. Patient Name (Please print) Patient or Parent/Guardian Signature Date Acknowledgement and Consent for Treatment Naturopathic Medicine and Acupuncture (to be completed by the adult patient, or parent/guardian if patient is a minor)
Request to Collaborate with Other Health Care Professionals Patient Name: Date of Birth: Check one: The patient does does not have a relationship with a licensed physician or pediatric health care provider. Name, address, phone number of licensed physician or pediatric health care provider: (Optional) Yes, I would like the Naturopathic Doctors to collaborate with my other health care providers. I may revoke this consent by a request in writing at any time of my choosing. Patient (or Parent/Guardian) signature Date
ACKNOLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Please sign and return to office to attest you accept the privacy practices This notice summarizes how health data about you may be used and shared and how you can get access to this data. IMPORTANT NOTE: This does not include all of the details about our privacy policy. For more details, please read the NOTICE OF PRIVACY PRACTICES that your practitioner has provided you. I. How we may use and share health data about you: a) Treatment - To give you medical treatment or other types of health services. b) Payment - To bill you or a third party for payment for services provided to you. c) Health Care Operations - For our own operations such as quality control, compliance monitoring, audit, etc. II. Disclosures where we do not have to give you a chance to agree or object: a) To you b) As required by federal, state, or local law c) If child abuse or neglect is suspected d) Public health risks (for public health activities to prevent and control spread of disease) e) Lawsuits and disputes (in response to a court or administrative order) f) Law enforcement (to help law enforcement officials respond to criminal activities) g) Coroners, medical examiners and funeral directors h) Organ or tissue donation facilities if you are an organ donor i) To avert a threat to an individual or to public health safety III. Disclosures where we have to give you a chance to agree or object: a) Patient directories - You can decide what health data, if any, you want to be listed in patient directories. b) Persons involved in your care or payment for your care - We may share your health data with a family member, a close friend, or other person that you have named as being involved with your health care. IV. Other uses of health data: Other uses not covered by this notice or the laws that apply to us will be made only with your written consent. V. You have the following rights relating to the health data we keep about you: a) Right to inspect your health record and to receive a copy of your health record upon request b) Right to amend information in your health record you believe is inaccurate or incomplete c) Right to know to whom we have disclosed your health information d) Right to ask for limits on the health information data we give out about you e) Right to receive communication from us about your health information in alternate ways f) Right to a paper copy of the complete Notice of Privacy Practices I acknowledge that I have received the NOTICE OF PRIVACY PRACTICES of this practice. Signature of patient or representative Date Print patient name Patient Birth Date Other persons approved to view or request copy of patient s medical records