By signing below, I am representing that:
I am at least eighteen (18) years old, and I am fully competent to give my consent;
I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed.
I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation.
This release shall be effective during the time the patient is under the care of the clinicians of the NeuroScience and TMS Treatment Center, or until it is revoked.
I understand that there is a statutory privilege that prohibits disclosure of communications between a patient and psychiatrist, psychiatric clinician, and therapist in Tennessee, and I hereby waive this privilege with regard to this release.
I may revoke this consent at any time except to the extent that the release has been completed.