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INFORMED CONSENT FOR THE NanoSRT WELLNESS SYSTEM

Patient Name

Address

Telephone Number.

City & State

Email:

Backqround: I desire to be tested to determine possible undesirable reactions to variousstressors that are natural constituents of my diet, environment or body chemistry. I

understand that the device being used is FDA cleared for Galvanic Skin ResponseTesting and not intended to directly treat or cure any specific condition, symptom orillness. The physician has explained, and I understand, the benefits of receiving stressreduction and relaxation therapy and the direct relationship between stress, illness anddisease.

Procedures: I understand that this is a non-invasive procedure (the skin is not pierced).A metal clip or electrodes are attached to the skin to measure electrical conductivity onthe hands. Homeopathic remedies, nutritionalsupplements and other natural remediesmay be used to bring abnormal electrical patterns into equilibrium. I understand thenature of the immune system and related symptoms are of an unpredietable nature andtherefore the facility cannot guarantee any results.

cannot guarantee that new stressors will notcontribute toward my health conditions in the future and that in some cases a personmay not wholly respond to the treatment.

I choose to be tested with the NanoSRT Standard-of-Care Wellness System. I understandthat this testing has not been scientifically proven to be reliable and that my physicianmust still rely upon my observations as to the efficacy of the test and any treatmentbased on the results of this test.

Risks: The procedure is very safe because it measures only changes in the electricalproperties of the skin. However, since an electrical signal is used there is a slight risk orelectrical burn or shock. Skin irritation or redness may occur at the site of the test.However, any discomfort should be brief. There are generally no risks associated withthe substances recommended to bring your body to equilibrium as long as thosesubstanees are taken as recommended, but please report any discomfort you mayexperience from taking these substances to your examiner or physician. Please reportany significant health problems (i.e. Diabetes, High Blood Pressure, etc.) to yourphysician. I understand that there is a risk factor where as a result of exposure to thesebio-energetic stressors, that I may experience temporary symptoms not unusual to the

NANG*n_

PLEASE CHECK OFF THE FOLLOWNG THAT APPLY TO YOU:

Digestive Track_nausea & vomiting_diarrhea_constipation_bloated feeling_stomach pains or cramps_heart burn

_blood and/or mucous in stools

Ears_itchy ears_ear aches/ear infections_drainage from ear_ringing in ears_hearing loss_reddening of ears

Emotions_mood swings_anxi ety/fear/n ervousn ess_anger/irritability/ag gressiveness

_argumentative_frustrated/cries easily_Depression

Eyes_watery or itchy eyes_red/swollen/itchy eyelids_bags or dark circles under eyes_blured or tunnel vision

Head

_headaches_faintness_dizziness_insomnia/sleep disorder_facial flushing_lrregular/Skipped Heartbeat_Rapid/Pounding Heartbeat_Chest Pain

Joints & Muscles_pains/aches in joints

_arthritis/osteoarthritis_stiffness/limited movement_pain/aches in muscles_feeling weaUtired_swo ll en/tend e r j oi nts

_growing pains in legs

_Psoriatic/Gouty Arthritis

_Rheumatoid Arthritis

Date

Lungs_chest congestion

bronchitis-rnortness of breath_difficulty breathing_persistent cough_wheezing

Mind_poor memory_difficulty completin g projects

_difficulty with mathematics_underachiever_poor/shot1 attention sPan

_confusion_easily distracted_difficulty making decisions

_mild learning Disabilities

Mouth & Throat Thrush_chronic coughing

_gagging/clearing throat often

-sore throaUhoarse voice/voice

loss_swollen/discolored tongue/li ps

_canker sores_itching on roof of mouth

Nose_stuffy nose_chronically red/infl amed nose

_sinus problems

_hay fever

_sneezing attacks_excessive mucous formation

Skin_acne_itching_hives/rash/dry skin_hair loss_flushing/hot flashes

Weight_binge eatin g/drinking

_craving certain foods_excessive weight_compulsive eating

water retention

General_frequent illness_frequenVurgent urination_genital itch/discharge_analitching

Genitourinary_kidney problems

_urinary tract_bladder_yeast infections

Other Gonditions_Autism

-A.D.H.D.-A.D.D._Psoriasis_Eczema_Auto lmmune Disorder_Chronic Fatigue_Multiple Chemical Sensitivities

_Asthma_Congestive Heart Failure_Severe Diabetic_Severe Depression

_Obsessive Compulsive Disorder

Patient Name

l\Ar-''C**,regular symptoms currently experienced when exposed to these stressors. I assume allresponsibility for the unpredictable immune reactions that may lead to increasedsymptoms. I agree to seek immediate medical attention should this occur andunderstand that this facllity does not treat cases of patients sufferlng from anaphylactlcallergic reactions and I agree to completely disclose all information regarding any lifethreatening allergies or allergies resulting in anaphylaxis.

Questions: I have been provided with the opportunity to ask any pertinent questions I

have regarding the NanoSRT procedure, protocol or treatment program.

Free to Dectine: t understand that t mav dectine to the NanoSRT testing and therapy.

lmpofiant: There is no recognized body of scientific evidence to show that an electricallybalanced body is more likely to be healthier and you have chosen to padicipate in thisassessment with that understanding. Your physician may need to use other forms oftesting in the course of your treatment.

Pavment of Services: You are responsible for the payment of the normal and necessaryfees associated with the NanoSRT Assessment and services performed as a result ofthat testing, if purchased in this clinic.

I have read and understand the above information about the NanoSRT Wellness System and myrights and responsibilities and hereby consent to the use of the NanoSRT Wellness System. I

consent to the use of clinical reports and results of my case for study, the purpose of advancingclinical knowledge, research and scientific purposes provided that my identity is kept confidential.

Date

Name Signature

Signature of Parent or Guardian if Patient is a minor