Responsible Party (if self, please just write self in first name box, leave the rest blank) First Name Last Name MI Date of Birth

Transcription

1 New Client Registration Radiance Now Nexalin Therapy Center Date: First Name: Last Name: MI: DOB: Address: City: State: Zip: Circle Primary: Home Work Cell Please indicate when you can be reached at each number Home Phone: Hours: Days: Work Phone: Hours: Days: Cell Phone: Hours: Days: address: Marital Status: Primary Care Provider: Gender: M F Preferred Language: Responsible Party (if self, please just write self in first name box, leave the rest blank) First Name Last Name MI Date of Birth Address City State Zip Home Phone Work Phone Cell Phone Relationship to Patient Preferred Language Emergency Contact First Name Last Name Preferred Language Relationship to Patient Address City State Zip Home Phone Work Phone Cell Phone I/We do hereby consent to and authorize the performance of all Nexalin treatments by Radiance Now Inc. to me or to the above-named minor of whom I am the parent or legal guardian. I hereby certify that, to the best of my knowledge, all statements contained hereon are true. I understand that I am directly responsible for all charges incurred for services for myself and my dependents.. I fully understand this agreement and consent will continue until cancelled by me in writing. Signature of Patient/Responsible Party Date Name of Patient/Responsible Party (Please Print) Relationship to Patient Radiance Now Inc. New Client Registration Form 2014

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4 Radiance Now Informed Consent I, _ hereby consent to Nexalin Advanced Therapy consisting of ten-fifteen (10-15) forty-minute (40-minute) sessions. I understand the importance of attending the initial ten (10) Nexalin Advanced Therapy sessions in order to receive the full benefit of the therapy. I hereby agree to make every effort to attend recommended and scheduled appointments. I understand that possible risk factors of Nexalin Advanced Therapy include headache, dizziness, nausea, and skin irritation at the site of electrode placement. There is also the possibility of experiencing a temporary increase of initial symptoms during the Nexalin sessions, these symptoms will usually diminish within 48 hours. I understand that the procedure will require application of three external electrode pads: one to my forehead and one behind each ear. These electrodes are sticky pads that will be removed at the end of each session. These electrodes will be connected to a Nexalin Device. The Nexalin Device is a painless, transcranial electrical stimulation device that delivers an electrical current to the area of the brain responsible for releasing and normalizing neurochemicals. I will hold harmless Nexalin Technology and all of its representatives and/or practitioners from any and all issues or behaviors that may occur as a result of my not following physician s instructions while receiving the Nexalin treatments. I acknowledge that the Nexalin center and its representatives, successors, and agents have not and cannot make any guarantees or assurances concerning the outcome or benefits of my therapy. I understand that after receiving the Nexalin treatment, I may develop a heightened sensitivity to any and all mood altering substances that may be prescribed to me or obtained through alternative channels, legal or illegal. I agree to follow all prescribing physician instructions during and after receiving the Nexalin therapy. I agree to notify the staff if I experience unusual symptoms after receiving a Nexalin Therapy session. _ I understand that neither Nexalin Technology nor Nexalin Therapy Center staff members recommend any prescribed medical prescriptions be altered in any manner from the prescribing physician's instructions or dosages. I understand that during and after any initial medical detox, using any mood altering substances can be hazardous to my health, unless prescribed and monitored by a physician Signature_ Date

5 Patient Brief History Record Name: Male Female For use by Therapy Center only: Patient ID: Primary Complaint: A D I Date of Birth: Month Day Year List your problem(s) (starting with your primary complaint) : Description of Problem Length of time you have had this problem Diagnosis/Doctor List any routinely scheduled medications and/or vitamins you currently take: Medication/Vitamin Dosage Times taken per day/route taken Reason Taken CLN16-FRM005-00

6 Patient Brief History Record Please list any sedatives you have taken within the past year: Medication Dosage List any other therapies you have tried and their effect (i.e., acupuncture, massage therapy, etc.) I = Improved or N = Not improved With my signature I confirm that the information given above is truthful and complete. Printed Name of Patient or Guardian Signature of Patient or Guardian Date CLN16-FRM005-00

7 U.S. Eligibility Criteria Some medical conditions have not been investigated and we do not know how people with these conditions would respond to Nexalin Advanced Therapy. Therefore, it is important that people who have had or currently experience any of the following conditions not be approved for Nexalin Advanced Therapy at this time. If you are unsure whether you have any of these conditions, please consult with your physician. Mark each item with a yes or no. Contraindication Yes No History of seizures, epilepsy, hydrocephalus, or tumors of the central nervous system. Acute brain injuries and infections. Break in skin integrity at the areas of electrode placement (forehead and behind each ear). Sensitivity to electrode gels or adhesives. Presence of any implanted electronic stimulators. Pregnant or may be pregnant at the time of therapy. Less than thirteen (13) years old. I understand that the presence of any of the above conditions precludes me from participating in Nexalin Advanced Therapy. With my signature, below, I hereby certify that the information I have provided is correct to the best of my knowledge. Patient Printed Name Patient Signature Date CLN30-FRM011-01

8 Radiance Now Cancelation and Financial Policy Hello, and welcome to Radiance Now, a Nexalin therapy center. We are excited that you have chosen to receive treatment at our center. We strive to provide a safe and relaxing environment for you, your family, and our other clients. In order to ensure that all clients receive the best possible service, we ask that you arrive 5-10 minutes prior to your scheduled treatment time. Rescheduling or Cancellation of an Appointment In order to be respectful of the needs of other clients, please be courteous and call Radiance Now promptly if you are unable to show up for an appointment. This time will be reallocated to someone who is in need of treatment. If it is necessary to cancel or reschedule your scheduled appointment, we require that you call at least 24 hours in advance. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to that appointment time. Appointments and cancelations that are made less than 24 hours ahead of time are billed at the normal appointment rate. Failure to show for a scheduled appointment will be treated as a failure to cancel in a timely manner. Payment All Nexalin therapy treatments must be paid in advance of the start of each treatment. You may choose to pay as you go, or to purchase a multi-treatment package. Please inquire with our office staff regarding the pricing for pre-paid packages. Refunds As with all health and wellness related services, specific outcomes cannot be guaranteed. Any treatments that have been completed will not be refunded. However, at any time, a client may request a refund of any unused prepaid treatments in the event that a multi-treatment package was purchased. Refunds will be made for the remaining unused treatments less any discounts that were applied to the original price of the treatment package. All refunds must be requested in writing at the Radiance Now office. Please feel free to bring any questions or concerns to our office staff. Name (Print): Date: Sign: ContactUs@RadianceNow.net Phone: (360) Radiance Now, a Nexalin Therapy Center Toll-Free:

9 Patient Instructions The following instructions are offered to help you receive the maximum benefit from your Nexalin Advanced Therapy. Please feel free to contact the Center at [telephone number] with any questions you may have. We ask that if you are currently taking any of the following medications, please hold them until after each of your Nexalin Therapy sessions: Atarax, Ativan, BuSpar, Centrax, Equanil, Librium, Libritabs, Miltown, Serax, Stelazine, Tranxene, and Valium. Nexalin sessions can put you into a deep restful state and these medications can enhance this effect. Please let us know immediately if this presents a problem for you. There is no need to fast before a Nexalin Therapy session. Eat as you normally do; however, be sure to hydrate adequately during your Nexalin Therapy experience. It is important your therapy not be interrupted, if at all possible. You will have an opportunity to use the restroom just before beginning each session. Please arrive at least 15 minutes prior to your scheduled treatment time. In order to respect the rights of other patients, children and pets will not be allowed in the Center under any conditions. Wear loose, comfortable clothing. Do not wear jewelry on your ears or around your neck, or makeup/lotion on your forehead or behind your ears. Reading, listening to music, or using laptops, cell phones, or any other type of electrical equipment is strictly prohibited. Your therapy environment should be calm, quiet, and comfortable. You are welcome to sleep during your therapy, if desired. You will have a way to contact your Nexalin Technician should you need assistance during a therapy session. Contact the Center the day before your scheduled appointment if you will not be able to keep your appointment. The Center staff will make every effort to reschedule your visit. If you experience an unusual sensation during your treatment, notify your Nexalin Certified Technician. Please use the space below to write down specific questions you may have before your treatment begins: _ Nexalin Therapy Center [ @therapycenter] [PHONE] CLN22-HND000-01

10 Patient Self-Evaluation-Anxiety Name: Date: Patient ID: This self-evaluation is for our information and education. Please answer the questions objectively, indicating how much you have been bothered by each symptom during the past week, including today, by circling the number in the column that most closely corresponds to how you ve been feeling. Not at All Mildly It did not bother me much Moderately It was very unpleasant, but I could stand it. Severely I could barely stand it. 1 Numbness or tingling Feeling hot Wobbliness in legs Unable to relax Fear of the worst happening Dizzy or lightheaded Heart pounding or racing Unsteady Terrified Nervous Feelings of choking Hands trembling Shaky Fear of losing ground Difficulty breathing Fear of dying Scared Indigestion or discomfort in abdomen Faint Face flushed Sweating (not due to heat) Patient Signature: TOTAL SCORE: CLN12-PSE000-00

11 Patient Self-Evaluation-Insomnia Name: Date: Patient ID: This self-evaluation is for our information and education. Please answer the questions objectively, indicating how much you have been bothered by each symptom during the past week, including today, by circling the number in the column that most closely corresponds to your sleeping patterns. 1. How long does it take you to fall asleep at night? 6. Do you often feel sleepy in the daytime? Less than 15 minutes 0 Never 0 Less than 30 minutes 1 Sometimes 1 About an hour 2 Most of the time 2 More than an hour 3 Always 3 2. How often do you wake up in the middle of the night? 7. Do you feel down, depressed, or under a lot of pressure? Never 0 Not at all - Never 0 1 time 1 Some of the time 1 2 times 2 Most of the time 2 3 or more times 3 Always 3 3. How long does it take you to fall back asleep when 8. Do you sleep for less than 5 hours a night? you wake up in the middle of the night? Never wake up 0 Never 0 Less than 10 minutes 1 Some of the time 1 Within an hour 2 Most of the time 2 Few hrs or can never go back to sleep 3 Always 3 4. Do you wake up very early in the morning and find 9. Do you sleep for more than 9 hours a night? it hard to get back to sleep? Never 0 Never 0 Sometimes 1 Some of the time 1 Most of the time 2 Most of the time 2 Always 3 Always 3 5. After a full night of sleep, do you feel well rested? 10. On weekends, what time do you go to bed? Always 0 8 p.m. to 10 p.m. 0 Most of the time 1 10 p.m. to Midnight 1 Sometimes 2 Midnight to 2 a.m. 2 Never 3 2 a.m. or later 3 CLN14-PSE002-00

12 Patient Self-Evaluation-Insomnia 11. On weekends, what time do you get up in the morning? 15. Finish this sentence. Upon awakening, the night: 5 a.m. to 7 a.m. 0 Passed more quickly than normal 0 7 a.m. to 9 a.m. 1 Passed normally 1 9 a.m. to 11 a.m. 2 Passed slowly 2 After 12 noon 3 Was extremely long How worried are you that you won t be able to get 16. How much movement occurs during the night? to sleep? Not worried at all 0 Same position I went to sleep in 0 Slightly worried 1 Different position than I went to sleep in 1 Moderately worried 2 Was aware of moving positions 2 Extremely worried 3 Was very restless Are you easily awakened by sounds/noises in the night? 17. Finish this sentence. My dreams were: No, not at all 0 Vivid and almost real 0 Slightly 1 Normal 1 Moderately 2 Sparse or I don t remember them 2 Extremely 3 Nonexistent How much does the quality of the sleep affect your next 18. Are you interested in finding out about how to day functions (i.e. fatigue, mood, irritability)? sleep better? Never 0 Yes 0 Slightly 1 Somewhat 1 Moderately 2 I don t care either way 2 Extremely 3 No, not at all 3 TOTAL SCORE: Patient Signature: CLN14-PSE002-00

13 Treatment Pricing All Nexalin treatments must be ordered by a physician. We work with Dr. James Hu out of Seattle. Consultations with him are done via phone, with all of the necessary paper work returned to Radiance Now ahead of time so that we can ensure that Dr. Hu receives it for your consultation. Payments for Dr. Hu s services are paid directly to him, and are not generally covered by insurance. You can make your payment to Dr. Hu by Cash, Check, Debit, or Credit Card. The fee for his consultation is $ The nexalin treatments are $295 per treatment. All treatments must be paid for in advance of the treatment. We offer discounted pricing if you purchase your full treatment package (10 or more treatments) as a bundle. Packages are discounted $50 per treatment. Regular price 1 treatment x $ treatments paid individually = $2,950 Package price 10 treatments x $245 = $2, (a savings of $500 over the individual pricing) Radiance Now accepts cash, check, debit, and credit (Visa, Mastercard, Discover, American Express). Client signature: Date:

14 Credit Card Authorization Please return this credit card authorization if you wish to pay Dr. Hu via credit or debit card. Dr. Hu will also accept cash or local checks. Dr. Hu s consultation fee is $ Credit card authoization: I authorized Dr. James Hu to charge my credit card in the amount specified below, for medical services rendered. Card Type: Number: Expiration Date: Authorization Code (3 digits on the back): Amount Authorized:_ Cardholder signature: Date: Print name:_