Eileen C. Comia, M.D.
35 Jolley Drive Suite 102
Bloomfield CT 06002
Tel (860)242-2200
Fax (860)242-2212
Page 1 of 2
1. A number of open published trials of the medical interventions have been conducted showing
evidence of efficacy. However, no double-blind crossover trials which represent the gold standard as
far as the medical profession is concerned currently exist. Although some are unproven in terms of
efficacy, these interventions and treatments present minimal risk of harm and are based on scientific
research and logic.
2. These interventions form a part of the overall individualized plan for an individual. It is not a
substitute for appropriate education, care, and health management. It entails a lot of patience,
determination and resiliency from all - the physician, the patient, and the family.
3. Although ultimately benefiting from these therapies, a small percentage of individuals may show
transient regression (i.e. die-off reaction from anti-fungal medications) during these treatments.
However, there are methods employed to minimize and manage these untoward reactions.
4. At present, it is difficult to determine which patients will benefit from these therapies with great
accuracy. Some individuals who may be perfect candidates may not have any improvement; while
others who seem to have little reason to recommend therapy will show marked improvement. In
general, the only way to determine this is to attempt treatment and observe the response.
5. Since medicine is an art as well as a science, and since each patient’s situation includes variables that
are unique and at times not fully understood, there is no guarantee that satisfactory results will be
I knowingly and willingly give my consent on behalf of myself or my minor child. I have had ample
opportunity to discuss the nature, the risks and benefits, anticipated costs, and the reasoning for the
treatments. I understand that medical treatment is an evolving art and that treatment results are not
guaranteed or may result in unexpected adverse events. While my doctor and the staff will take
reasonable precautions to ensure my safety or my child’s safety, I am willing to assume the risks of
treatment whether known or unknown. I am seeking treatment in order to further my own or my child’s
health and for no other reason.
Eileen C. Comia, M.D.
35 Jolley Drive Suite 102
Bloomfield CT 06002
Tel (860)242-2200
Fax (860)242-2212
Page 2 of 2
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
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