CONSENT TO TREAT: I, legal adult patient or the legal guardian, consent for myself or the patient (the “Patient”) to receive medical care, testing and treatment by Sozo Brain Center LTD (the “Center”) and the providers. This may include medically necessary examinations, treatments, prescribing and recommending screenings and questionnaires, diagnostic testing, laboratory procedures, in-office procedures, arrangement for healthcare services, emergency services by the provider, other licensed staff members or staff under the supervision of licensed provider for this visit, future visits, and telehealth visits. Patient understands the providers may include physicians, nurse practitioners, physician assistants, and other clinicians as well as students, trainees, and clinicians both employed and not directly employed by the Center. I am fully aware that the members of the Center use neuromodulation technologies and complementary therapeutic methodologies. I freely consent to the trial use of these technologies off-label, beyond the limits proposed by manufacturers when this is recommended for my condition. I acknowledge that these methods and technologies function complementary to and in no way replace medical treatments or the need to continue to consult my treating physicians.
Patient understands the right to consent or refuse to consent to any medically necessary treatment or procedure, except as otherwise required by law. Patient understands they have the right to discuss all medical treatments with the providers. Patient understands that the practice of medicine is not an exact science, and that diagnosis and treatment may involve the risk of injury or death. Patient understands that no guarantees have been made regarding diagnosis, treatment or care the Patient may receive. Patient understands that this consent to treatment must be approved and/or signed, in order, for the Patient to be seen and will be considered valid until such time that the Patient revokes this consent in writing.
CONSENT TO TELEHEALTH: Patient agrees to care and treatment involving the use of electronic communications between the Patient, legal guardian, and provider transmitted by telephone and/or by video or other transmitted information to a provider who is at a different place than the Patient. Telehealth services allows healthcare providers at remote locations to share the Patient’s medical information for diagnosis, therapy, follow-up, and education purposes. Patient gives consent and authorizes the Center and the providers to forward the Patient’s information to a third party as needed to receive telehealth services, and Patient understands that existing confidentiality protections apply.
Patient understands that while telehealth services can be used to provide improved access to medical care, as with any medical service or procedure, there are potential risks. These risks include but are not limited to technical problems with the information transmission and equipment failures that could result in lost information or delays in treatment. Patient understands that they have a right to withhold or withdraw their consent to the use of telehealth services during treatment at any time, without affecting the Patient’s right to future treatment.
CONSENT TO MEDICATION HISTORY: Patient authorizes the Center and providers to request, providers and/or third-party pharmacies as necessary for treatment purposes. Patient further authorizes the Center to communicate with the Patient’s treating physicians regarding medication interactions and therapeutic compatibility.
Patient acknowledges receipt and review of detailed information regarding all neuromodulation technologies and treatment methodologies offered by the Center, including but not limited to (where applicable): Newronika, Nurosym, Flow Neuroscience, PlatoScience, and other non-invasive neuromodulation devices and techniques.
Patient confirms understanding that:
(a) The Center has provided comprehensive information regarding the indicated uses, contraindications, potential side effects, and instructions for use as provided by all manufacturers;
(b) The Center has explained that manufacturers recommend limited use of these products, and Patient freely consents to trial use of these technologies beyond manufacturer-recommended limits when clinically recommended for the Patient’s condition;
(c) These technologies are non-invasive and complementary to standard medical care;
(d) Use of these technologies in treating chronic conditions represents emerging clinical practice and may involve trial/experimental protocols;
(e) No refunds will be provided once device packaging has been opened;
(f) All manufacturer documentation, instructions, and safety information have been made available and explained;
(g) Patient has been given full opportunity to ask questions, and all questions have been answered to Patient’s satisfaction.
Patient confirms voluntary and informed consent to proceed with neuromodulation therapies as recommended by the Center’s clinical team.
MEDICAL TEACHING & TRAINING: Patient understands and gives consent to the providers, clinicians, and other health professionals may be involved in training during the Patient’s treatment. Patient understands and give consents to the Center and providers to allow non- employees, such as students and associated health care providers who are participating in educational programs, access to the patient care areas. Patient understands that they may have access to incidental health information. Patient understands they have the right to question the provider regarding such training and can choose not to authorize such access during the Patient’s examination and treatment.
MEDICAL IMAGES: Patient authorizes photos and/or videos may be made of the Patient for the purpose of care or medical teaching and maybe published on the Center’s webpage, providers on-line portals and/or social media platforms. These materials may be used for clinical teaching, medical education, and professional development purposes and in educational presentations to healthcare providers and students. Patient understands these images may also be stored in the Patient’s medical record in a secure manner that will protect the Patient’s privacy. The images will be kept for the time-period as required by law. Moreover, I consent for the relevant videos, photos and written testimonials to be published across the Center’s social media platforms. I understand and consent that the scientific faculty and clinical team of the Center have the right to edit, modify, adapt, reproduce, distribute, and use these materials in whole or in part, worldwide and in perpetuity (unless I revoke consent), and may include clinical data, diagnoses, treatment information, and raw footage material regarding my condition and neuromodulation treatment process. I acknowledge that I reserve the right to withdraw this consent at any time in the future as described on the Privacy Policy which can be found at [link to Privacy Policy] . I understand any information used or disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected by the applicable laws. I understand that this authorization can be revoked at any time to the extent that the use or disclosure has not already occurred prior to my request for revocation.
RELEASE OF HEALTHCARE INFORMATION: Patient authorizes the Center to share the Patient’s protected health information for treatment and payment purposes with the non-custodial adults listed below when these individuals bring the Patient to his/her visits. Patient understands they have the legal right to preauthorize treatment, and request that the Center deliver medical treatment when the legal guardian is unable to be present for the Patient’s visits and may the legal guardian telephonically. However, I understand that this authorization to treat is not contingent upon their ability to successfully reach myself as the Patient’s legal guardian.
USE AND DISCLOSURE OF INFORMATION: Patient consents to the use and disclosure of information from the Patient’s medical records, including protected health information, by the Center for treatment, payment, and health care operations as permitted by law. All uses and disclosures will abide by the terms identified in the Notice of Privacy Practices.
Patient authorizes the Center to release all medical records upon request directly to the Patient’s educational institute and/or day care facility. Patient understands this authorization will remain in effect until such time the Patient revokes this consent in writing. Patient understands that, in order, to restrict disclosure of medical records, the Patient must request and complete the Request for Limitation and Disclosure of Protected Health Information Form, which would include the Patient’s medical records.
ASSIGNMENT OF BENEFITS AND FINANCIAL AGREEMENT: Patient hereby assigns and authorizes payment of invoices or bills directly to the Center. Patient understands they are financially responsible for any charges not paid for any and all services as provided by the Center and/or it’s providers. Patient authorizes the release of Patient’s health and financial information to the applicable payer, including but not limited to any commercial and/or governmental payers. All fees must be paid at the time at which services are rendered unless prior arrangements have been made . At the time of the visit, the Patient understands the person who brings the Patient to an appointment may also be financially responsible.
The Center may assess fees for missed appointments, returned checks for insufficient funds, and collections activities. Patient acknowledges they understand and accept the Missed Appointment Policy.
OFFICE POLICIES: Patient has reviewed any office policies that have been presented, and any questions regarding the policies have been answered to my satisfaction. Patient agrees to comply with the policies.
CONSENT TO ELECTRONIC COMMUNICATION: Patient authorizes the Center to use Patient’s information to send reminders regarding upcoming appointments, to obtain feedback on the practice experience and to provide general health information via telephonic/voice calls as well as e-mail and/or text messaging.
PATIENTS RIGHTS AND RESPONSIBILITIES: The Patient has received and/or reviewed General Consent for Treatment, Financial Agreement & Release form and a copy of the SOZO Brain Center’s Patient’s Rights and Responsibilities or opted to download an electronic copy from the website.
To the fullest extent permitted by law, I release and hold harmless SOZO Brain Center LTD, its officers, directors, employees, agents, and affiliated providers from any and all claims, liabilities, damages, or causes of action arising from:
(a) The creation, use, publication, or distribution of multimedia materials, clinical data, and treatment information;
(b) Medical treatment, neuromodulation therapy, or evaluation services provided;
(c) Any editing, modification, or adaptation of materials by the Center or third parties;
(d) Third-party misuse or re-disclosure of released information;
(e) Technical failures or breaches in telehealth services;
(f) Unintended consequences or unexpected outcomes of disclosed information;
(g) Search engine indexing or indefinite accessibility of published materials.
I acknowledge that this release applies to injuries or damages that may occur as a result of treatment, however caused, except in cases of gross negligence or willful misconduct.
By selecting this section, Patient acknowledges that they have received information on the Notice of Privacy Practices and GENERAL CONSENT FOR TREATMENT, FINANCIAL AGREEMENT, & RELEASE FORM, which sets forth the ways in which health information may be used or disclosed by the Practice and outlines the Patient’s rights with respect to such information. Patient understands the Notice is also available on the Practice’s website or in the office upon request. By checking the box, Patient certifies they have read, understood, and agreed to the terms on this General Consent, Financial Agreement, and Release Form. Patient certifies that information given of the Patient’s identity, demographic, financial, and/or Pay information is truthful. Patient certifies that they were given the opportunity to ask questions and all questions (if any) have been answered to their satisfaction.
By selecting this section, the Patient understands that they may revoke this authorization, and that the revocation will become effective on the date it is made and will not apply to health information already released or exchanged.