NeuroModulation Technique (“NMT”) is intended to
determine the patient’s
perception of conditions contributing to illness. I
desire to be screened with
NMT, and hereby consent to participate in this type of
screening and correction
process.
The procedure has been explained to me, and I
understand that certain adverse
effects may result from application of NMT. These
could include, but are not
limited to, a temporary soreness in muscles of the
arms tested, or a temporary
flare‐up of my symptoms. Other possible side effects
include symptoms of
heightened immune function or detoxification such as
fever, chills, headache or
body aches.
I understand that NMT‐
The Feinberg Method©
is not a medical diagnostic
procedure, and therefore does not diagnose disease.
Diagnosis requires
particular types of clinical examination procedures by a
physician trained in
diagnosis. By contrast, NMT is intended to determine
the patient’s perception of
conditions contributing to illness. I understand that
Muscle Response Testing,
(“MRT”) employed in NMT, like any medical testing
procedure, is not 100%
accurate.
I understand that alternative methods of treatment are
available. These have
been described to me. If I am suffering from severe
allergenic reactions to
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NMT‐ Comprehensive Seminar Notes 070606
substances, I will consult an appropriate physician and,
if so advised, take
medication (to prevent itching, tissue swelling, fever,
cough, pains, etc.) to keep my symptoms under control
while I am being receiving care with NMT‐
The
Feinberg Method©.
I understand that determination of the existence and
identification of particular infectious agents in the
body requires specific laboratory testing. NMT‐
The
Feinberg Method©
does not diagnose any infectious agent, nor is it a
substitute for
appropriate laboratory testing. Rather, NMT evaluates
the perceptions of the
ACS and immune system with regard to such issues, and
attempts to optimize
autonomic function with respect to immune system
control.
NMT‐
The Feinberg Method©
is not a method of diagnosing or treating cancer.
Medical oncologists are the only health care personnel
appropriately trained to
manage the treatment of cancer. NMT is not a
substitute for appropriate medical
care of cancer.
I agree to cooperate and take an active role in my
care by maintaining a positive
attitude regarding NMT, continuing contact with and
treatment from medical practitioners, and communicating
progress and side effects to the health care
provider administering NMT. I understand that I am to
continue all medication
and other treatment modalities as they have been
prescribed unless otherwise
directed by the doctor who prescribed them.
I understand that there is no guarantee and/or claim
made concerning the effect,
therapeutic or otherwise, of receiving NMT. I
understand that it is possible that
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NMT‐ Comprehensive Seminar Notes 070606
some health care regulatory agency or other entity may
interpret that the NMT
and/or the NMT Treeview system is investigational or
experimental within the
context of some particular health care scope of
practice. I also understand that it
is possible that some health care regulatory agency or
entity may interpret that
NMT and/or the NMT Treeview system is used to produce
a direct therapeutic
effect on a patient. I understand that the NMT
developer and the party
administering the NMT session (hereinafter the “NMT
Practitioner”) specifically
disavow any direct therapeutic effect of the NMT
Treeview system and claim
only that the system is intended to enhance the
efficiency of assembling the data
that comprises the NMT session, which otherwise proceeds
as a direct interaction
of the NMT Practitioner and Patient, just as when NMT
is not used. The goal of
the NMT session is always to provoke or induce a
better physiological response
in the client.
I also understand that the developer of NMT and the
NMT Practitioner make no
claims as to use or direct effects on the client of
the scalar antenna. I understand
that NMT Practitioners have reported that the use of
the scalar antenna enhances
the efficiency of muscle response testing by the NMT
Practitioner and it has been
provided for such possible convenience. Additionally, I
understand that the use
of the personal scalar antenna is for investigational
purposes only and will be
used with an MP3 playback of the NMT session
material. I understand that I
will not be separately charged for the use of the
scalar antenna during a NMT
session.
I understand that I am free to discontinue care at
any time, but acknowledge that
I am responsible for full payment of the normal and
necessary fees associated
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NMT‐ Comprehensive Seminar Notes 070606
with my screening and care. I also understand that the
NMT Treeview system is
a database management system for the purpose of
enhancing the efficiency by
which the NMT Practitioner executes the NMT session.
Additionally, I
understand that clinical data is presently being
collected on the technique that
requires the gathering of certain information in
accordance with research
protocols. I understand that the results of this study
may be published in a
medical or scientific journal, and that a number or
letter designating my case, but
not my name, may be used in reports of this study.
I understand that it is possible that third party
payers may interpret that NMT
and/or the NMT Treeview system is investigational or
experimental and may not
pay for use of NMT and/or the NMT Treeview system in
healthcare. I also understand that no billing should
ever be made to third party payors for the use
of NMT Treeview in surrogate or remote applications in
any case.
I acknowledge being informed of all material facts
related to the screening and
NMT program of care, including but not limited to the
nature and character of the care proposed, the nature
and character of the anticipated results of this care,
the recognized possible alternative forms of treatments
and the recognized
serious possible risks, complications and possible
benefits involved in the
treatment and in the recognized possible alternative
forms of treatment,
including nontreatment.
I have read, or have had read to me, the above
statements, and have been
provided with the opportunity to ask any pertinent
questions I have regarding
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author.
NMT‐ Comprehensive Seminar Notes 070606
this screening and NMT program of care. I have been
informed that I am to
contact the doctor as soon as possible if any problems
are encountered during
my care.
I understand the conditions stated above, and hereby
consent to
participate in this type of screening and NMT care. By
signing below I agree to
the terms and procedures set forth above.
IN WITNESS WHEREOF, I have executed the foregoing this
__day of ______,
_____.
_____________________________________
____________________________________
Patient’s Signature
Patient’s Printed Name
_____________________________________
____________________________________
If minor, signature of parent or guardian
Parent or Guardian’s Printed Name
_________________________________
__________________________________
Practitioner
Witness
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