Healthcare NanoFuel Form

HEALTHCARE NANO FUEL FORM — CONSENT & AUTHORIZATION

Patient Information

Date of Birth:    Gender:

Primary Phone:    Email:

Insurance Information

Policy Number:    Group Number:

Medical History & Current Status

Chronic Conditions (check all that apply):

Diabetes    Hypertension    Heart disease    Autoimmune disorder    None of the above

Are you currently pregnant, breastfeeding, or planning a pregnancy within the next 6 months? Yes No

NanoFuel Treatment Description

NanoFuel is a proprietary therapeutic agent intended to augment cellular metabolic processes when administered by the medical team. Administration may be by intravenous infusion, localized injection, or topical application as determined by the treating clinician. The anticipated benefit is measurable symptomatic improvement or tissue response; however results cannot be guaranteed.

Treatment schedule proposed:

The patient acknowledges that NanoFuel is being offered as: Standard of care Investigational / limited data

Risks, Benefits, and Alternatives

Known common reactions may include localized pain, swelling, transient fever, headache, nausea, or fatigue. Serious but less frequent risks include allergic reaction (anaphylaxis), organ dysfunction, infection at the administration site, thrombotic events, or systemic inflammatory responses. There may be unknown long-term risks associated with NanoFuel therapy. The patient acknowledges receipt of oral explanation of these risks.

Reasonable alternative treatments (including no treatment) were discussed:

Consent & Authorizations

By checking the boxes below and signing, the patient gives informed consent and authorizes the use of NanoFuel as described. Consent covers pre-treatment evaluation, administration, routine monitoring, and standard emergency interventions related to this therapy.

I consent to receive NanoFuel therapy and associated care.

I consent to the collection and analysis of my de-identified clinical data for quality assessment and research purposes.

I consent to clinical photography or video recording for documentation or educational use (identifying features will be protected unless I authorize otherwise).

I authorize disclosure of treatment information to my insurer for billing and determination of benefits.

HIPAA Authorization & Release of Records

I authorize release of my relevant medical records and treatment information related to NanoFuel therapy to the following individuals or entities for continuity of care and payment purposes.

Purpose of Disclosure:

Expiration of this authorization (date or event):

I authorize the release as specified above and understand I may revoke this authorization in writing except to the extent action has already been taken.

Right to Withdraw & Withdrawal Procedure

I understand I have the right to refuse or withdraw consent at any time. Withdrawal must be submitted in writing to the treating facility; withdrawal will not affect actions already taken based on this consent prior to receipt of revocation.

Clinical Follow-up & Reporting

The patient agrees to attend scheduled follow-up visits and to report adverse events promptly. Emergency instructions were explained and contact information provided.

Certification of Understanding

I certify that I have read (or have had read to me) the information in this document, that the procedure, risks, benefits, and alternatives have been explained, and that all of my questions have been answered to my satisfaction. I understand the above and consent to the treatment and authorizations indicated.

Patient Initials:

Sign Now