Informed Consent Agreement
Nutritional Consultation, NeuroModulation Technique (NMT) - Local and Remote Session Consent Form

Directions: Please complete each page of this form in its entirety. Each page will give you instructions for the section below it. If you should have any questions please email for support!

Sign in to Google to save your progress. Learn more
Email *
Today's Date *
Client's Full Name *
Your relationship to client:
Please place your initials under each section of text to indicate you have read and understand what is written.
I understand that Autism Transformed's Nutritional Consultation and NMT is intended to determine the client's nutritional and biochemical status that may be contributing to illness behaviors and to guide the client to a healthier, less dysfunctional state through dietary changes, nutritional supplements and other means. I understand that the Nutritional Consultation and NMT that is conducted either on a local in-office or a remote basis in which I do not attend the practitioners office and further stipulate that I understand that the remote Nutritional Consultation and NMT is not considered to be a medical treatment, or therapy of any kind. *
I understand that the remote Nutritional Consultation and NMT is considered a telephone consultation and that this is the service which I hereby request and for which I am being charged and will pay the agreed upon rate I have been given in document or email form. I am requesting local and/or remote Nutritional Consultations and application of NMT from Heart Full Healing or Autism Transformed - Luminara Serdar located at: 466 West 17th Ave, Eugene, Oregon, 97401 USA. Remote sessions may be conducted via telephone, Skype, or other video call format when I am unable or do not wish to physically visit the office. I understand that under no circumstances is it appropriate to bill my medical insurance for any remote NMT sessions and agree that I will not submit such bills to my insurance. Further, I understand that remote and in-office NMT sessions may be considered investigational and may not be paid by my health or other insurance. If allowed, I may utilize my employer Health Savings Account (HSA) to deduct these as alternative and complimentary health services. *
The NMT procedure and Nutritional Consultation process has been explained to me, and I understand that certain adverse effects may be associated with changes in diet and the addition of nutritional supplements or local or remote NMT sessions that could include, but are not limited to, 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, and agree, that if any unexpected exacerbation of my symptoms should occur, if any medical emergency should occur, that I am solely responsible for obtaining appropriate medical care to address those symptoms or conditions, and will do so in a timely manner. *
I understand that medical diagnosis requires particular types of clinical examination procedures by a physician trained in diagnosis and that Nutritional Consultations and NMT applications are not a medical diagnostic procedure, does not diagnose any disease, and that Nutritional Consultation and NMT evaluation procedures are not a substitute for physical examination, laboratory testing, medical imaging or other diagnostic procedures. I understand that Muscle Response Testing, (“MRT”) employed during a Nutritional Consultation is not 100% accurate and is only an indication of client perceptions and not an objective measure of body conditions. I understand that my local or remote Nutritional Consultation and NMT practitioner may utilize surrogate muscle response testing in which muscle response from the practitioner or other third party is used as an indicator of response to the semantic queries and statements the practitioner inquires of the mind-body of the client. *
I understand that alternative methods of treatment are available and have been described to me. If I am suffering from severe allergic reactions to food or other substances, or any health condition for which I have been prescribed medications to control dangerous symptoms, 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 engaging in Nutritional Consultations and NMT applications. *
I understand that determination of the existence and identification of particular infectious agents or cancer in the body requires specific medical laboratory testing. NMT and Nutritional Consultations do not diagnose any infectious agent, or cancer, nor is it a substitute for appropriate laboratory testing.  Rather, NMT evaluates the patient’s mind-body perceptions with regard to such issues and attempts to direct a more effective immune system response by changing mind-body self awareness. *
NMT and Nutritional Consultations are not methods of diagnosing or treating cancer. Medical oncologists are the only health care personnel appropriately trained to manage the treatment of cancer. NMT and Nutritional Consultations are not a substitute for appropriate medical care of cancer, or any other health care condition. I understand that I am not being asked to discontinue any concurrent medical care. Moreover, I understand that it is recommended that I do not discontinue any care prescribed by my doctors. *
I agree to cooperate and take an active role while receiving remote NMT sessions and engaging in Nutritional Consultations, by maintaining a positive attitude toward healing, continuing contact with and treatment from my other medical practitioners, and communicating progress and any possible side effects or new symptoms that may or may not be related to my NMT session, to my NMT practitioner, or to my dietary interventions recommended by this 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 also understand that improvement in my health resulting from the NMT sessions and Nutritional Consultations I am requesting, may result in a change in my requirement for medications other providers have prescribed for me, and will consult that medical provider to see if a change in medication or medication dosage is necessary. *
I understand that there is no guarantee concerning the effects of the NMT sessions or dietary changes based on the Nutritional Consultation. I understand that I am free to discontinue NMT sessions and Nutritional Consultations at any time, but acknowledge that I am responsible for full payment of the normal and necessary fees associated with my NMT sessions and Nutritional Consultations. If I agree to a Healing Session Package and do not complete the number of sessions in the Package, I understand that I am responsible for payment of all of the assessments outlined in my Package. I also understand that I am responsible to return the zinger scalar antenna or pay $75 for it. I understand that if I terminate the NMT sessions and the recommended dietary changes without the recommendation of my NMT practitioner and Nutritional Consultant, that this may adversely influence the degree or durability of my improvement.  I agree that if I have allergies causing dangerous symptoms such as anaphylactic response, or any condition that is aggravated by certain activities or exposures, that I will not expose myself to such risk of aggravation except as advised by my NMT practitioner under controlled and defined circumstances. I understand that if I expose myself to such aggravating factors prematurely, this may pose a risk to my health. *
I understand that any services that are being provided on a local or remote basis are my sole financial responsibility, and that no aspect of such services may be billed to insurance companies for the purposes of reimbursement. I understand and authorize all charges for this service to be billed to the credit card account I have provided or that such services will be paid by the time the service is provided by other means. I understand that these charges will be billed under the name:  Luminara Serdar or Autism Transformed at the rate of: provided in the healing package document, or other written form, sent to me. I understand and agree that office policy requires 24 hour notice to cancel a previously scheduled appointment and I will be charged the full fee or if a session in a package, that session will be used and cannot be made up, for such appointments canceled without 24 hour notice. *
I understand that the NMT session results in the selection of portions of the NMT protocol that the NMT practitioner finds appropriate for me and that this information is communicated to my mind-body by way of intention. I further understand that if the NMT Scalar system is used in my NMT care that this computerized system will simply assemble this information that has comprised my NMT session in the form of an MP3 or other format audio data file. That data file may be provided to me for the purpose of playing on a media player using a special scalar antenna. The purpose of this use of the audio data file is to modulate the scalar field produced by use of the file with the scalar antenna in such a way as to create a scalar representation of that NMT session information. I understand that the scalar field has no known medical effect and that the purpose of using this scalar output of the audio data file is based on the unproven possibility that this scalar representation of the data from my NMT sessions might be perceivable by my mind-body and if so, might thereby reinforce any informational training effect that such NMT sessions may have. I also understand that if I perceive any adverse effect that I associate with the use of this scalar playback that I will immediately stop using it and notify my NMT practitioner. *
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 NMT session program or Nutritional Consultation. I have been informed that I am to contact the doctor if any problems are encountered during or after my NMT sessions, or Nutritional Consultation and recommended dietary changes, and agree to do so. I understand the conditions stated above, and hereby consent to participate in these local and/or remote NMT sessions and Nutritional Consultation and recommended dietary changes. I have read the package terms in its entirety and agree to submit all payments in the schedule provided to me. By signing below I agree to the terms, procedures, and permissions set forth above. *
IN WITNESS WHEREOF, I have executed the foregoing on this day *
Client’s Signature (type full name below):
If minor, parent or guardian’s signature (type full name below):
You have reached the end of the form. Thank you!
466 West 17th Ave, Eugene, OR 97401 tel +1 541-359-2855 / 541-653-0446
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy