Consent Forms


Naturopathic & Nutritional

Consent Form

Dr. Humaira Quraishi ND, MS

    [email protected]






I hereby consent to the performance of Nutritional & Naturopathic treatments and other procedures within the scope of the practice of naturopathic medicine on me (or on the patient named below, for whom I am legally responsible) by the naturopathic doctor named below and/or other licensed naturopathic doctors who may in the future treat me while employed by, working or associated with the naturopathic doctor named below, whether signatories to this form or not.

I understand that methods of treatment may include, but are not limited to: botanical medicine, nutritional counseling, physical medicine, medical intuitive counseling, hydrotherapy, homeopathy, and flower essences. I will immediately notify the doctor listed below of any unanticipated or unpleasant effects associated with the herbs, remedies or supplements.

I have been informed that, while naturopathic medicine is a generally safe method of treatment, side effects are always a possibility.  The recommended herbs, remedies and nutritional supplements (which are from plant, animal and mineral sources) while  traditionally considered safe, can be toxic in large doses. I understand that these remedies may also interact with some medications and I have fully disclosed all of the medications I am currently taking and will disclose any new medications I may be placed on in the future.  I understand that the herbs, remedies and supplements should be consumed according to the instructions provided orally and in writing.  I understand that some herbs and supplements may be inappropriate during pregnancy or breastfeeding.  I will notify the naturopathic doctor who is caring for me if I am or become pregnant or am currently breastfeeding.

I understand that the naturopathic doctor may not be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the naturopathic doctor to exercise judgment during the course of treatment.  I understand that results are not guaranteed and my own cooperation and effort plays a big role in the success of my treatment.

I understand the clinical staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent.

By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of naturopathic medicine and other procedures, and have had an opportunity to ask questions.  I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions(s) for which I seek treatment.



Consent for the Collection, Use and Disclosure of Personal Information


I understand the importance of protecting the privacy of your personal information and I am committed to collecting, using and disclosing your personal information responsibly. I am aware of the sensitive nature of the information that you have disclosed to me; therefore, I strive to ensure that:

  • Only necessary information is collected about you.
  • I only share your information with your consent.
  • Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols.
  • My privacy protocols comply with privacy legislation, the standards of our regulatory body, and the law.


I will collect, use, and disclose information about you for the following purposes:

  • To assess your health needs and advise you of health management options.
  • To communicate with you and remind you of upcoming appointments.
  • To communicate with all other health care providers in your health care team.
  • To allow me to efficiently follow up for health management, care and billing.
  • To assist in complying with all regulatory requirements and the law, including requirements to advise authorities of child abuse and to report diseases and individuals who may be an imminent threat to themselves or others.
  • To invoice for goods and services, process payments, and collect unpaid accounts.


If a new purpose arises, I will seek your written approval in advance. I will not, under any circumstances, supply your insurer with your confidential medical history. In the event that this kind of request is made, I will forward the information directly to you for review and for your specific consent.


Patient Consent: I have reviewed the above information that explains how my naturopathic doctor will use my personal information. Should the need arise, I agree that my naturopathic doctor can email me and I understand that this is not considered a secure form of communication. I agree that my naturopathic doctor can collect, use and disclose my personal information for the purposes listed above.


Email Communication Consent


Email offers an easy and convenient way for patients and doctors to communicate. In many circumstances, it has advantages over office visits or telephone calls, but here are important differences. Email is not the same as calling our office; there is no person at the other end of the call – just a computer. You can’t tell for certain when your message will be read, or even if your doctor is in the office or on vacation. Nonetheless, we believe that the ease of communication email affords is a benefit to patient care. It will further assist us if you could identify the nature of your request in the subject line of your message. Below are our rules for contacting us using email.


  • Email is NEVER appropriate for urgent or emergency problems. Please use the telephone or go to the Emergency Department for emergencies.
  • Email is great for asking those little questions that don’t require a lot of discussion.
  • Emails should not be used to communicate sensitive medical information, such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability or substance abuse.
  • Email is not confidential. You should also know that if sending emails from work, your employer has a legal right to read your email.
  • Email may become a part of the medical record when we use it; a copy may be printed and put in your chart.
  • Email is not a substitute for seeing a doctor. If you think that you might need to be seen, please call and book an appointment.
  • In cases where an email response would not be appropriate or sufficient, you may be asked to schedule an appointment to ensure that your concerns get properly addressed.
  • For more complex inquiries that require the doctor to review your medical chart and provide an in depth response, it is my policy to charge $30 for this email service.


I have read this Email Communication Consent form and understand the limitations of security on information transmitted. I understand that my doctor may not be able to communicate with me electronically about my specific condition if I live outside of the state in which my doctor is licensed.



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Signed by Dr. Humaira Quraishi
Signed On: 3 December 2019

Dr. Humaira Quraishi ND, MS
Signature Certificate
Document name: Consent Forms
Unique Document ID: 57d3a128f45861e875d464b020ae5453b85f12ae
Timestamp Audit
3 December 2019 5:07 pm EDTConsent Forms Uploaded by Dr. Humaira Quraishi - [email protected] IP