Mandatory Consent Form

Consent Form

By signing the form below, I understand and acknowledge that Heidi Dahlenburg will not suggest or advise me to delay or refuse standard-of-care treatment for my cancer diagnosis. Heidi believes in standard-of-care treatment as a necessity and will not treat patients who choose to treat their cancer with alternative therapies alone. Standard-of-care therapies include chemotherapy, radiation, targeted therapy, hormone therapy, and immunotherapy. This also includes clinical trials that your oncologist suggested to you. It is strongly recommended you regularly liaise with an Oncologist to monitor your cancer and deal with any treatment or disease-related effects. Heidi aims to work with you to provide integrative suggestions that could help improve well-being, reduce side effects, and increase treatment response. However, the nature of the disease does not guarantee a positive result. I, the undersigned patient or legal guardian, acknowledge that I have read and understood the disclosure terms and conditions provided below and consent to the integrative care outline by Heidi Dahlenburg.

Disclosure Terms and Conditions

Heidi Dahlenburg Qualifications.

Heidi has undertaken the following accredited tertiary study:

• Bachelor of Health Science (Nursing)
• Advanced Diploma of Naturopathy
• Graduate Certificate in Advanced Practice Nursing, with Distinction.
• Masters of Professional Nursing (currently undertaking)

Heidi has been in the Healthcare profession for 24 years, starting as a Naturopathic Clinician and then moving into nursing. Heidi's main areas of nursing included rural emergency and Intensive Care. In 2018, Heidi began working at the National Institute of Integrative Medicine and has since continued in this field with a specific focus on cancer. Heidi has a special interest in Integrative Therapies for Chronic Health Conditions. Heidi continues to work as a clinical nurse consultant for several general practitioners.

Approach to Integrative Therapies

Heidi believes in personalised therapies, focusing on your unique situation. This approach may involve functional testing and analysis to determine factors such as gut microbiome health, hormone balance, and toxicity. Lifestyle factors such as mental health, past trauma, and lifestyle are addressed to have a complete picture of your current health status.

Collaboration with Medical Specialists.

Heidi believes that the best care is given when collaborating with your multidisciplinary team. Heidi is happy to work alongside your team. This requires full, written consent from all parties.

Scope of Practice

Under Integrative Care, Heidi works within the scope of a Naturopathic Practitioner. Heidi can suggest other healthcare providers that may suit your needs if necessary. Heidi is unable to prescribe medication or diagnose. Under her qualifications, Heidi cannot provide bulk-billed pathology testing; however, she can order functional testing at the patient's expense. Heidi can look at documentation already reviewed and discussed by your medical provider/ team.

Medical Information

You must provide all requested documentation before your appointment. This generally includes pathology, PET/CT reports, genetic testing, and histology results. This ensures that a complete history is taken so more time can be spent in the consultation discussing interventions.

Consultation and Billing.

Consultations are by appointment only. Initial appointments must be 75 minutes. Fees:

• Initial Appointment (75 minutes) $250
• Follow-up Appointment (30 minutes) $110

Payment is required upon booking as Heidi spends considerable time reviewing your information before the appointment. A payment link will be sent to you when a booking time is agreed upon. All consultations are done via the Zoom platform. There are no rebates on Naturopathic Services due to Government Regulations imposed since the 1st of April 2019.

Cancellation

Heidi requires no less than a 24-hour cancellation notice. This ensures that the appointment slot can be offered to another person. Cancellations can be sent via email to heidi@integrativecare.com.au. Any late cancelations or no-shows will be charged 50% of the consultation fee.

Supplement and Tinctures.

Heidi sells limited supplements but will suggest places to purchase any recommended items. Heidi does provide custom herbal tinctures (MediHerb), which include blends of medicine to address your unique, personal requirements. Heidi, to the best of her knowledge, suggests supplements and herbal medicine that have known safety profiles and have been shown potential in the context of their application in humans. Heidi strives to identify herb/drug interactions, but data may not be lacking, or interactions may be unknown. High-standard clinical trials for these applications may be lacking, but Heidi seeks to keep recommendations evidence-based.

Communication via email/text

By signing this form, I consent to communicate with Heidi at Integrative Care via email, online forms, and/or text. I acknowledge that email, online forms, and text communication may not be completely secure, and any decision to use such communication will be documented in your clinical record. I understand that confidentiality will be respected, and emails and/or texts will not be forwarded without all parties' consent; I am signing to confirm that I know the conditions set out above and have been made aware of the associated risks concerning data protection. Heidi cannot call or email patients outside of a consultation to answer any medical or health-related questions; these must be done in the context of a consultation. Heidi suggests checking your consultation summaries and making a follow-up appointment if required.

Protocols and Meeting Notes

Protocols will be provided to you within 7 days of your consultation.

Attendance and Follow-up

I am consulting with Heidi voluntarily and consent to receive and undertake treatment suggestions based on my judgment from the information provided to me. I understand that results vary between different individuals. I will return for a review of my care at the timeframe suggested by Heidi. If I fail to attend these reviews, I will no longer follow the suggestions made in the protocol. I understand that prolonged taking of certain supplements or lifestyle measures (e.g., fasting) can lead to adverse health outcomes. I understand that supplements/protocols are prescribed for me and should not be shared with anyone else. Any information sheets provided to you remain Heidi's intellectual property and must not be shared with other parties or on social media.

Confidentiality

All information gathered in the provision of medical services will remain confidential and secure except where:

1. There is a serious and imminent risk to yourself or someone else
2. There is reasonable suspicion a child is at risk or is being mistreated
3. A court subpoenas your records
4. Your prior approval has been obtained to provide a written report to a requested professional agency (e.g.specialist, university, lawyer, etc) or to discuss information with another person (e.g., family member, employer)

Telehealth Consent & Information

Heidi predominantly utilises vCITA (clinical management) and Zoom to deliver telehealth services. Privacy remains as per our usual process. Refer to the Confidentiality section in this document, and we will treat your information respectfully and confidently. We will not record or share material from telehealth sessions without your consent. Telehealth services utilise interactive cloud-based systems that involve sharing audio, video, or other data communication online (outside of our practice). Heidi commits to privately undertaking these calls so others cannot hear your information. We recommend that you also find a private setting where you feel comfortable. You must take steps to protect your information. If you cannot find a private location where you feel relaxed, let Heidi know when she calls, and she will respect your request. Your privacy is important, and we will respect your decision.

Payment

A payment link will be sent to you via email/text. Payment is due upon booking. Cancelations must be emailed to heidi@integrativecare.com.au at least 24 hours before the appointment. There is the option of keeping your payment details on file.

Acknowledgment:

By signing below, you acknowledge that you have read and understood the disclosure, terms, and conditions outlined above. You know the nature of our health practitioners' practice and have consented to the terms and conditions.