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Alternative Therapy

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 Alternative Therapy Consent

  • Informed Consent For Alternative Therapy

  • For The Use Of Direct, Indirect, Autonomic Response, Kinesiological and Cranial/Structural Diagnostic testing and Bio-frequency Therapy
  • I hereby authorize the use of alternative treatment upon myself, by Dr. Judson B. Wall. I understand that these methods are considered experimental. Direct, Indirect, Autonomic Response, Kinesiological and Cranial/Structural Testing have been explained as simple, non-invasive methods developed by recognized experts in their respective professional fields (Yoshiako Omura, MD [Direct and Indirect Testing], Dietrich K. Klinghardt, MD, PhD [Autonomic Response Testing], George Goodhart, DC [Kinesiological Testing], Gerald H. Smith, DDS [Cranial Indicator Tests], Major B. De Jarnette, DC [Structural testing], Brian Rothbart, DPM [KNEE BEND TEST]).

    Based on Energy Medicine, these diagnostic tests have been clinically shown to be more sensitive than conventional blood and other routine testing methods like MRI or CAT Scan in recognizing dysfunction within the body. When these diagnostic tests are integrated with bio-frequency and nutritional therapy and manipulative treatment and correction of dental malocclusion, the benefits have been clinically shown to be very effective.

    Potential Beneficial Effects: Relief of pain. Relaxation of spastic muscles. Structural realignment of the jaws, skull and neck. Relaxation of vasoconstricted blood vessels and subsequent vaso-dilation and improvement of circulations. Reduction of bacterial, viral and fungal pathogens. Enhanced drug and nutrient uptake in diseased areas where micro-circulation exists and very little drug or nutrients are absorbed.

    Potential Adverse Effects and Disadvantages: Use of concentrated nutrients can cause nausea, vomiting, lightheadedness, fatigue, acne, diarrhea, headache, muscle soreness and stiffness. Correction of dental malocclusion can cause structural reactions anywhere in the body. These symptoms usually manifest in the form of muscle spasm, tension, disequilibrium, conductive hearing loss, visual disturbances (blurred vision). limited jaw opening, tenderness in the scalp, neck and low back. In addition, similar to conventional medical/dental treatment, unforeseen adverse effects can occur, including worsening of pre-treatment symptoms, which may or may not be related to the treatment provided.

    I have been made aware of the possibility of both complications and beneficial effects that may result from this treatment, and I indemnify Dr. Wall, his staff or heirs from any and all responsibility for such possible consequences. Hence, I will not blame, request any refunds or sue Dr. Wall, his staff, heirs or Dental Solutions, Inc. or location where such treatment was performed concerning any consequence of the test results or treatment. Furthermore I have been informed and understand that all treatment should be done in conjunction with a Physician of my own choosing.

    All my questions on the proposed treatment and alternative methods of treatment have been answered, and all the treatment procedures have been explained in detail to my satisfaction. I authorize Dr. Wall to use the alternative treatment methods on me, to take photographs of myself before, during and after treatment, to publish the findings regarding the effectiveness of treatment related to my condition on Dental Solution’s website or other professional publication. I understand that I am free to withdraw at anytime from further treatment from Dr. Wall.

    I have read this informed consent and understand it. I am not a minor (under the age of 18). Additionally, I am here on this day and any subsequent visit, solely on my own behalf and not as an agent for any foreign or domestic federal, state, or local agencies on a mission of entrapment or investigation.

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After submitting, feel free to return to the Patient Forms page. Please note, there are multiple forms for each section.

 

 

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