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PATIENT ENROLLMENT AND CONSENT FORM
Type name as signature

Physician: Ann Shippy, MD

Functional Medicine is defined as a system of medical thought and practice that focuses on optimal functioning of the whole person, the entire body and its organs, which involves integrating systems of conventional and integrative medicine.

In many instances, the treatment plans do not follow standard medical practice, or what is considered to be the medical ?standard of care?. Standard medical practice focuses on treating a particular diagnosis or disease process rather than focusing on the individual as a whole.

When deciding to be treated by Ann Shippy, MD, there are two main issues to which you will need to agree to before a consultation or any treatment will begin.

Consent

I hereby request personalized Functional Medicine evaluations and treatment, based on my own particular health concerns, and developed in a partnership with Ann Shippy, MD. These treatments may include diagnostic or therapeutic procedures including various modes of therapy for myself (or the patient named below, for whom I am legally responsible) by Ann Shippy MD, including nurse staff members working at the clinic.

1. I understand that Ann Shippy, MD is not a primary care doctor. Ann Shippy, MD is a specialist in Internal and Functional medicine, and will be developing a personalized health plan that considers the many aspects of my health and wellness.

2. By signing below, I acknowledge that Ann Shippy, MD is not replacing my primary care provider and/or specialist trained in treating any condition with which I have been previously diagnosed. My primary care practitioner or urgent care provider is likely who I will see for ?standard of care? protocols.

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