against Eleazar M. Kadile, M.D.
1400 E Washington Ave
PATIENT NAME AND FULL ADDRESS:
AGE AND SEX:
Malignancies, diseases, illnesses or physical conditions diagnosed for medical treatment by EDTA chelation therapy (list all):
My physician has explained to me and I fully understand:
(a) There are two forms of ethylenediaminetetraacetic acid (EDTA) that have been approved for use in humans by the U.S. Food and Drug Administration (FDA). The two forms are distinctly different. Disodium EDTA is only approved and labeled for treating abnormally high calcium levels (hypercalcemia) and life-threatening digitalis toxicity. Calcium disodium EDTA is only approved and labeled for lead intoxication;
(b) The FDA has NOT approved or labeled the drug disodium EDTA to be used for conditions other than hypercalcemia or life-threatening digitalis toxicity. The FDA has NOT approved or labeled the drug calcium disodium EDTA for any condition other than lead intoxication;
(c) that EDTA chelation therapy has NOT been established through controlled trials to be effective for the treatment of circulatory diseases, specifically including atherosclerosis, hardening of the arteries (arteriosclerosis), vascular insufficiency, diabetes or any other condition beyond those mentioned in (a);
(d) that the federal government and most insurance companies do NOT pay for or reimburse for treatment with EDTA chelation therapy for vascular conditions;
(e) that the medications in the EDTA chelation mixture could interact with other medications I am taking, could cause a medical emergency, and my other physicians should be informed of all ingredients in the EDTA chelation mixture, for my protection.
(f) that neither the American Medical Association, the American Osteopathic Association, the American College of Cardiology, the American Heart Association, the American College of Physicians, or the American Academy of Family Physicians, recommends the use of EDTA chelation therapy for the treatment of any human disease, illness, malady or physical condition other than those for which it is labeled;
(g) That therapy with EDTA chelation may not be begun until three days have expired after the date of my execution of this informed consent form, unless I have furnished records showing that I am presently receiving chelation therapy from another physician.
I have read and understand the above. Having read and understood the above, I hereby elect to undergo treatment with EDTA chelation therapy.
Patient signature and date: