Informed Consent Agreement for Treatment

Thomas Rogers, DC

11701 Hobbiton Trail, Austin TX 78739
Austin 512 282-6628 Houston 713 990-9500

 

Chiro Plus + Kinesiology (CPK), and NeuroModulation Technique (NMT) are two non- conventional tools used by Dr. Thomas Rogers and are intended to determine the patient’s perception of conditions contributing to illness. I desire to be screened with CPK, and NMT, and hereby consent to participate in this type of screening and treatment. 

I understand that certain adverse effects may result from treatment. These could include, but are not limited to, a temporary soreness in muscles tested, or a temporary flare up of my symptoms. Other possible side effects include the symptoms of heightened immune function or detoxification such as fever, chills, headache, or body aches. 

I understand that CPK, and NMT are not medical diagnostic procedures, and therefore do not diagnose disease. By contrast, CPK, and NMT are intended to determine the patient’s perceptions of conditions contributing to illness. I understand that Muscle Response Testing, (MRT) or the use of other biofeedback mechanisms employed with CPK and NMT, like any medical testing procedure, are not 100% accurate. 

I understand that alternative methods of treatment are available. 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, coughs, pains, etc.) to keep my symptoms under control while I am being treated with CPK, and NMT. 

I understand that determination of the existence and identification of particular infectious agents in the body requires specific laboratory testing. CPK, and NMT do not diagnose any infectious agent, nor is it a substitute for appropriate lab testing. Rather, CPK, and NMT evaluate 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. 

CPK, and NMT are not methods of diagnosing or treating cancer. Medical oncologists are the only health care personnel appropriately trained to manage the treatment of cancer.

CPK, and NMT are not substitutes for appropriate medical care of cancer. 

I understand that nutritional, herbal, or homeopathic products recommended for use in Dr. Rogers’ office are not meant to diagnose, treat, or cure any disease. These supplements can result in possible side effects. Possible side effects include but are not limited to the symptoms of heightened immune function or detoxification such as fever, chills, headache, or body aches.

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 the health care provider administering CPK and/or 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 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 and treatment. I further understand that I am financially responsible for any cancellation or delinquency of appointment without 48 hours notice.

I also understand that clinical data is presently being collected on the techniques that require 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.

I have executed the foregoing on the date stated below.