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Low Dose Informed Consent Agreement 2 - NMT - drbloem

Low Dose Informed Consent Agreement 2 - NMT - drbloem 2026

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The document is an informed consent form for patients agreeing to undergo Low Dose Naltrexone (LDN) therapy prescribed by Dr. Fred Bloem. It outlines the purpose of LDN, its use in treating various health conditions, particularly cancer and autoimmune diseases, and the potential side effects. The document emphasizes that LDN is considered experimental and off-label, requiring careful monitoring and lifestyle considerations. Patients acknowledge understanding the risks, benefits, and alternatives to treatment before consenting.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name in the designated field at the top of the form, ensuring accuracy for identification purposes.
Read through the consent details carefully. This section outlines the purpose and potential effects of Low Dose Naltrexone therapy.
Initial each page after reading to confirm your understanding of the information provided, as indicated on the form.
In the signature section, sign your name to indicate consent and agreement to proceed with treatment under Dr. Bloem's supervision.
Fill in the date of signing to complete this section of the agreement.
If applicable, have a parent, legal guardian, or caregiver sign where indicated, ensuring all parties are informed and consenting.

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