Functional Medicine Disclaimer
Dr. Matt le Roux, B.Sports, M.Chiro, IFMCP, is not a primary care physician (GP) or psychiatrist. His consultation services do not include the treatment or diagnosis of specific illnesses or disorders. If you suspect that you have an ailment or disease requiring urgent medical attention, you must consult a licensed physician immediately. Only a licensed physician can prescribe drugs. Any mention of drugs during the consultation is only to provide a complete history of the drugs you are taking and not for Dr. Matt le Roux to judge the appropriateness of the medication. Any change in prescription or dosage needs to be made by your primary care physician.
Dr. Matt le Roux focuses on wellness and prevention of illness through non-toxic, natural nutritional therapies to achieve optimal health. As a certified functional medicine specialist, Dr. Matt le Roux primarily educates and motivates clients to assume more personal responsibility for their health by adopting a healthy attitude, lifestyle, and diet. While people generally experience improvements in their health and wellness by embracing a healthier lifestyle and diet, Dr. Matt le Roux does not promise or guarantee protection from future illness.
By signing below, you acknowledge that you understand that Dr. Matt le Roux is a functional medicine practitioner and not a primary care physician. You should see your GP if you have an urgent medical condition. Dr. Matt le Roux will not be held liable for failure to diagnose or treat an illness, nor for failure to prevent future disease. You also acknowledge that you have given Dr. Matt le Roux a complete and accurate account of any medical conditions and medications you are taking.
Care Program
Functional and Lifestyle Medicine involves recommending lifestyle, dietary, and supplement changes based on your history and test findings. It uses the most recent research to assess the body, emphasizing the relationship between your body and your internal and external environment. The relationship between you and the Functional and Lifestyle Medicine provider includes mentorship and guidance towards achieving a healthy balance within your body. No diagnoses are made, and no treatment for pre-existing conditions will be rendered. Functional and Lifestyle Medicine addresses the underlying pathophysiology that may contribute to prior diagnoses.
Laboratory Testing
Functional laboratory testing involves evaluating nutritional, biochemical, and physiological imbalances. These lab tests are not intended to diagnose a disease but to identify functional imbalances in your body and allow your practitioner to make appropriate recommendations. This testing does not replace testing provided by your medical physician. It is your responsibility to follow up with our office for the results of all testing and laboratory procedures. Health/medical recommendations and/or possible referral and additional follow-up may be warranted based on laboratory testing and evaluations. Some or all tests may not be covered by your insurance company, and you assume full responsibility for the costs of non-covered tests. Dr. Matt le Roux and his employees or contractors do not file for insurance for these tests.
Consent
I acknowledge that I have discussed or had the opportunity to discuss with my functional and lifestyle medicine provider the nature and purpose of the consultations and the contents of this consent form. I agree to accept the care program of my own free will and have read the consent form in its entirety. I consent to functional and lifestyle medicine and/or biofeedback and neurofeedback therapy for the duration of this program and any future consultations required. While people generally experience greater health and wellness because of embracing a healthier attitude, improving their lifestyle and diet, supplement protocols, and brain balancing programs, Dr. Matt le Roux and his employees or contractors do not promise or guarantee improvement of your condition or protection from future illness.
By signing below, you acknowledge that you understand that Dr. Matt le Roux is a chiropractor and certified functional medicine practitioner with the Institute of Functional Medicine (IFMCP). He is not a medical doctor and does not claim to be. Any advice provided is intended as health coaching and not as medical advice, treatment, or diagnosis. If you believe you have a medical condition, you are advised to see your doctor. Dr. Matt le Roux and his employees or contractors will not be held liable for failure to diagnose or treat an illness, or for failure to prevent future illness. You also acknowledge that you have given Dr. Matt le Roux and his employees or contractors a complete and accurate account of any medical conditions and medications you are taking.
Recommendations
All recommendations are made in your best interest. The functional medicine practitioner and/or health coach may not be able to anticipate all risks and complications. You will keep your medical doctor fully informed about any changes in supplements, diet, and any other pertinent information. You must consult your medical doctor if you want to make any changes to your medications.
Primary Care Physician
Dr. Matt le Roux and his employees or contractors are not your primary care physicians. We recommend that you have a primary care physician at all times during your care with us. You are advised not to stop your prescription medications without consulting your prescribing physician.
The Risks of Using Electronic Communications
Dr. Matt le Roux and his employees or independent contractors cannot guarantee but will use reasonable means to maintain the security and confidentiality of electronic communications sent and received. We take appropriate precautions when transmitting emails to avoid unintentional disclosures. Dr. Matt le Roux and his employees or independent contractors are not liable, however, for improper disclosure of confidential information not caused by our intentional misconduct.
Transmitting patient information through electronic communications can be risky. For example, secured and unsecured email messages can be intercepted, circulated, altered, forwarded, stored, or used without authorization or detection. Messages may be misaddressed, read by employers and online service providers, easily falsified, retained after deletion, used to introduce viruses, or used as evidence in court.
Still Want to Use Email and Other Electronic Communications?
If you want to use email or other electronic methods to communicate with us, we have some final instructions:
We cannot guarantee your emails will be read promptly, so please do not use email or electronic contact for urgent matters.
Follow up with us by phone if you expect a return response and do not receive one within two business days.
Notify us promptly if your email address changes. Be aware that electronic communications become a part of your health record.
Email will not be used to share sensitive medical information, such as communications about AIDS/HIV, mental health conditions, sexually transmitted diseases, or substance abuse.
I understand the risks associated with communicating by email and give my consent for the practice to send my protected health information through electronic means. If I have any questions, I will contact the practice’s privacy officer.
Chiropractic Disclaimer
By Australian law, all practitioners who adjust the spine are required to inform patients of the potential risks associated with the treatment.
In extremely rare circumstances, treatments of the neck may damage a blood vessel, potentially leading to a stroke or stroke-like symptoms. While this has never occurred in our practice, we are obligated to inform you of this possibility. If any adjustments (manipulations) are required, you will be tested beforehand, as has always been our practice.
Other very slight risks include strain or injury to a ligament or disc in the neck (less than 1 in 139,000) or lower back (1 in 62,000). Chiropractic adjustments (manipulations) of the spine are internationally recognised as being far safer in dealing with neck and low back pain than medication and many other alternatives (A Risk Assessment of Cervical Manipulation, JMP, 1995; Manga Report, Ontario Ministry of Health, 1993).
If you have any questions related to the treatment you are about to receive, please do not hesitate to ask your chiropractor.
Purpose of Chiropractic Care
Chiropractic care involves the assessment, diagnosis, and treatment of musculoskeletal conditions, primarily related to the spine and other areas of the body. Techniques may include spinal adjustments, mobilisation, soft tissue therapy, exercise prescription, and lifestyle advice.
Potential Benefits
Relief from pain and discomfort
Improved mobility and posture
Enhanced nervous system function
General health and wellness benefits
Risks & Complications
While chiropractic care is generally safe, there are some potential risks:
Temporary soreness, stiffness, fatigue
Headache or dizziness
Rare risks such as disc injury or vascular complication
We encourage you to ask questions at any time.
Privacy Statement
All information provided is kept confidential by the Privacy Act 1988 (Cth) and the Australian Privacy Principles.
Indemnity Clause
By submitting this form, I agree to release and indemnify Dr. Matt le Roux from any liability, claims, or demands related to my participation in chiropractic care, to the extent permitted by law.