Fill and Sign the Consent Patient Form

C onsent to Neurointegration Therapy and Release of Physician and Clinic from Liability Consent and release executed on the __________________________ (date) by ______________________________ (Name of Patient) of ____________________________ ____________________________________________________________________________ (street address, city, county, state, zip code) , hereinafter called Releasor , to and in favor of and _______________________________________ (Name of Corporation) , a professional corporation organized and existing under the laws of the state of __________________, with its principal office located at ________________________________________________________ _____________________________________ (street address, city, county, state, zip code) , herein sometimes referred to herein as Clinic or Releasee . Whereas, it is the opinion of the medical staff of Clinic that Releasor would benefit from the following described Neurointegration Therapy (describe Therapy ) ___________________ ________________________________________________________________________ ; and Whereas, Releasor has been advised by Clinic as to the dangers associated with, and possible complications from, such Therapy, said dangers and complications being (describe fully) _______________________________________________________________________ ________________________________________________________________________; and Whereas, certain physicians and certified therapists at Clinic are qualified and willing to perform the Therapy; and Whereas, before such Therapy will be performed, Releasor must consent to the Therapy and must release the physician and/or certified Therapist who propose to perform the Therapy, as well as other Clinic employees, officers, and directors from all liability that may result from the Therapy. Now, therefore, for and in consideration of the Therapy to be performed and any further Therapy that may, in the opinion of the medical staff of the Clinic be necessary, Releasor, fully realizing that such Therapy may be unsuccessful, that it may have certain complications, including, but not limited to, (describe in detail) _____________________________________ ____________________________________________________________________________, requests that such Therapy be performed, and consents to the Therapy . Releasor releases and forever discharges Clinic, Clinic's physicians, certified therapists, as well as all employees, officers and directors of Clinic, from all claims, damages and causes of action that may arise from the Therapy described in this Consent and Release, and from other medical care arising from the same. Releasor agrees that no representations have been made regarding the success of this Therapy, except as set forth in this Consent and Release . This R elease shall be binding on ____________________________ (Name of Patient) , his/her spouse, and on the heirs, legal representatives and assigns of Releasor. Releasor has read all the terms of this instrument and understands that he/she is signing a complete release and bar to any claim resulting from the Therapy described in this Consent and Release . Witness my signature as of the day and date set forth above. _______________________________ _________________________________________ Witness Name and Signature of Patient