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INFORMED CONSENT

I understand that Bubbling Spring Wellness offers treatments using acupuncture; electro-dermal screening, NeuroModulation Technique, BioSet allergy elimination technique, applied kinesiology; herbal, homeopathic and nutritional remedies, all of which are available to me as a patient of Daniel I. Ebaugh, M.Ac., a licensed acupuncturist in the State of Maryland.

Acupuncture: The procedures and processes used in acupuncture treatment have been fully explained to me and I understand I may be treated with the insertion of needles, and /or with the application of heat (moxa) to the skin. I further understand that the Federal Government has deemed the use of Acupuncture "experimental" as it is not yet a common practice in this country.

NeuroModulation Technique (NMT) is an alternative non-invasive technique, which uses "Muscle Response Testing" (MRT) to communicate with the Autonomic Control System (ACS). As a computer programmer corrects "glitches" in computer code, NMT corrects faults in the body's ACS, in order to move it toward normal function. Each step of the NMT correction involves muscle testing for ACS faults, and then delivering the appropriate "query/ correction" script to reset the ACS for optimal function. I have read Dr. Leslie Feinberg's article on the NMT process and I understand that my practitioner has been trained in the Advanced NMT technique. I have not been promised success or any specific results concerning treatment with this protocol.

A Remedy Search is based on the fundamental principles of energetic medicine. Using the latest computerized, biofeedback technology or Muscle Response Testing to communicate with the body's inner intelligence, we evaluate body functions from an energetic perspective. Then we ask the body to tells us which remedies or combinations of remedies are required to bring it back to balance. Dosage is determined in the same manor.

I have read the following information pieces written or edited by Daniel I. Ebaugh, M.Ac., L.Ac. "Classical Acupuncture," "NeuroModulation Technique, A Safe, Effective and Rapid Method of Restoring the Body's Inherent Capacity to Heal," and "Eliminating Allergies Without Drugs or Shots." All of my questions about these different treatment modalities have been answered.

RISKS/SIDE EFFECTS I am aware Acupuncture may result in certain side effects including local bruising, slight bleeding, fainting, temporary pain or discomfort, and temporary aggravation of symptoms existing prior to treatment.

NMT, BioSet, and Hormone Balancing are all a non-invasive techniques and nothing is placed inside the body. Therefore, the risk of side effects is minimal. However, during the coarse of treatment, I understand it is possible that I might experience certain typical detoxification symptoms such as fatigue, digestive upset, headache, insomnia or restlessness. Additionally, I understand, as a result of the healing process (Homeopathic Law of Cure), my symptoms may get worse before they get better. If such an aggravation of symptoms or detox reaction lasts more than 48 hours, I agree to contact my practitioner. Further, I agree that my practitioner shall not be responsible for these or any other side effects from the any of these treatments.

TREATMENT I herby voluntarily consent to be treated with energy medicine in the form of Acupuncture, NMT, BioSet, and/or Hormone Balancing as administered by Daniel I. Ebaugh, M.Ac., L.Ac., an acupuncturist licensed in the State of Maryland. I understand that other methods of testing and treatment for my symptoms are available to me and I choose to be treated using these nontraditional methods.

I desire to be muscle tested to determine if, from an energetic perspective, there are faults operating within my Autonomic Control System (ACS ) and if so, I want the ACS reset for optimal function using NMT protocols.

I desire to be muscle tested and or Electro Dermal Screened to determine if, from an energetic perspective, my bodily functions are balanced or if I need herbs and homeopathics.

I desire to be muscle tested to determine possible undesirable reactions to various substances that are natural constituents of my diet, environment or body chemistry.

I understand that neither muscle testing nor Electro Dermal Screening has been scientifically proven to be reliable and that my practitioner must still rely upon my observations as to the efficacy of the test or treatment.

I am aware that if there is a worsening of my ailment or condition or if it does not improve within the time estimated by my practitioner at the beginning of treatment, I should consult a licensed physician.

I understand that other methods of testing and treatment for my symptoms are available to me and I choose to be treated using the methods described above. Further, I understand that (1) I may decline to participate in any of the above-mentioned forms of treatment at any time; (2) I am free to stop taking the recommended supplements/remedies at anytime; and (3) I can choose, any time, to be treated with traditional Western medicine.

I have not been promised success or any specific results concerning this treatment.

I understand that I am responsible for payment of the normal and necessary fees associated with my tests, treatments, nutritional supplements and remedies.

PRINT NAME OF PATIENT: _____________________________________________

SIGNED BY: __________________________________________________________

DATE: _______________________________________________________________

WITNESSES BY: _______________________________________________________

Bubbling Spring Wellness, 10605 Concord St., Suite 410 Kensington, MD 20895

 


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