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Informed Consent Agreement

NMT: The Feinberg Technique Treatment Consent Form

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 treatment.

The procedure has been explained to me, and I have read Leslie Feinberg’s article entitled “Neruomodulation Technique”. I understand that certain adverse effects may result from the treatment.  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 fatigue, digestive upset, headache, insomnia, fever, chills, headache or body aches. Further, I agree that my practitioner shall not be responsible for these or any other side effects from the NMT treatments.  

I understand that NMT: The Feinberg Technique is not a medical diagnostic procedure, and therefore does not diagnose disease, including cancer.  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 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 treated with NMT: The Feinberg Technique.

I understand that determination of the existence and identification of particular infectious agents in the body requires specific laboratory testing.  NMT: The Feinberg Technique does not diagnose any infectious agent, nor is it a substitute for appropriate laboratory testing.  Rather, NMT evaluates the perceptions of the autonomic control system, and immune system with regard to such issues, and attempts to optimize autonomic function with respect to immune system control.

I agree to cooperate and take an active role in my treatment by maintaining a positive attitude regarding treatment, continuing contact with and treatment from medical practitioners, and communicating progress and side effects to Daniel Ebaugh, L.Ac., my NMT practitioner.  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 concerning the effect of the treatment.  I understand that I am free to discontinue treatment at any time, but acknowledge that I am responsible for full payment of the normal and necessary fees associated with my screening, treatments and nutritional supplements.

I also 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 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 this screening and treatment program.  I have been informed that I am to contact the doctor if any problems are encountered during my treatment.    I understand the conditions stated above, and hereby consent to participate in this type of screening and treatment.  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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