Eileen C. Comia, M.D.
35 Jolley Drive Suite 102
Bloomfield CT 06002
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Acknowledging the above, the fact that there is a sense of urgency in initiating these interventions, and
weighing the risks versus the significant potential benefits, I, (Patient Name)
_______________________________________ (Date of Birth) _____________ give consent to Dr.
Eileen Comia and her staff to administer biomedical intervention/s to me. I will not hold responsible Dr.
Eileen Comia, Advance Biomedical Treatment Center, or any of the center’s staff or any other person
associated with the medical intervention, for the physical and/or behavior problems as well as any injury
to myself, any injury to another person, and/or any form of emotional distress experienced by me.
By signing below, I have read and understood the Disclaimer and the Informed Consent above, have
understood the potential risks and benefits, and agree to receive biomedical treatments, following the
standards and principles of complementary, alternative, or integrative medicine.
Signature of Patient Date
PARENTAL CUSTODY and WAIVER
If the patient is a minor child, I certify that I am either the parent or the legal guardian, and that I have
custody for the purposes of authorizing medical treatment. I will hold Dr. Eileen Comia, Advance
Biomedical Treatment Center, and the staff harmless in the event there is a parental disagreement about
the medical care.
If a minor, both parents must give consent by their signatures below.
If only one parent has medical custody, that parent must attach a court document showing that he or she
has custody for the purposes of authorizing medical treatment. In the event that either parent withdraws
consent, such withdrawal must be in writing and the child will not be able to continue treatment.
If parents are divorced, please provide proof of legal child custody.
Signature of Father Date
Signature of Mother Date