Waiver and Release Form

Consent to Neurointegration Therapy and Release of Physician and Clinic from Liability

Consent and release executed on the by

of

hereinafter called Releasor, to and in favor of and a professional corporation organized and existing under the laws of the state of with its principal office located at

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 Release shall be binding on , 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.