NMT Article | | NMT
Treatment Details
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
