INFORMED CONSENT FOR APITHERAPY

APITHERAPY is the art and science of making therapeutic use of products of the honey bee hive, including honey, pollen, propolis, royal jelly, bees wax and bee venom. To be most effective this treatment requires a relationship of trust and confidence between Apitherapist and the RECIPIENT of APITHERAPY. Both parties must recognize the need to cooperate and work together.

I, the RECIPIENT, understand that:

• APITHERAPY is not a procedure approved by the US Food and Drug Administration, the American Medical Association, or any other regulatory agency in the United States.
• APITHERAPY addresses the whole body, including mind and spirit, in a holistic way.
• There are no clearly established protocols for APITHERAPY.
• Complications of APITHERAPY can include itching, swelling, bruising, infection, temporary discomfort and allergic reactions ranging from skin irritation or rash up to anaphylactic shock which can cause difficulty breathing, loss of consciousness and even death if not treated appropriately.
• The Apitherapist has made no guarantees or promises of any kind regarding the safety or efficacy or results of Apitherapy.
• The Apitherapist will take the actions I believe are reasonable and necessary to protect the health and safety of the RECIPIENT
• Alternatives to APITHERAPY may include surgery, medication, massage, spinal manipulation, medical treatment and advice, and a regimen of diet and exercise. All have been considered or tried and I have chosen to pursue APITHERAPY for relieving pain, enhancing wellbeing and/or improving my physical condition.

I have given the Apitherapist a clear, candid and complete disclosure of my medical history including problems, treatments and medications. I am not on Beta-blockers. Should I begin to exhibit signs of a significant allergic reaction, I authorize the Apitherapist to administer Epinephrine and/or an antihistamine.

The Apitherapist has advised me of the procedure planned. I have received a clear, comprehensive explanation of the risks inherent in APITHERAPY procedures and their possible adverse consequences, including death. I have discussed these matters with the Apitherapist, and am satisfied that the answers have been understandable, thorough and have adequately addressed my concerns. I am confident I have the information necessary to understand the risks and benefits of the procedure so I may give this informed consent. I understand that I am entitled to receive a copy of this consent form when it is executed.

I _____________________________ the Apitherapist, state that I have fully and frankly explained the risks and benefits of APITHERAPY, and pledge my best efforts to administer it in a proper manner based on my training, experience, and best judgment.

We, the Apitherapist and RECIPIENT, understand the cooperative nature of this treatment and understand our individual and each others responsibilities. We have read and understood this document, affirm the statements made above, and evidence our acceptance of the above terms by signing below.

Signed this _____ day of _____, 201__ at ___ ____________________

RECIPIENT_____________________  APITHERAPIST _____________________

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