By signing this form, I, or the parent/guardian, am aware that AVE involves pulsing lights to the eyes and tones to the ears. This process can evoke seizures in individuals with epilepsy and I testify that I and any person using this device has no history of seizures. I, or the parent/guardian, have been informed that individuals who have a history of epilepsy, brain seizure or any neurological condition should not experience AVE without first consulting a medical professional. 
 
I understand that if I, or my child, have had a recent brain injury or a mental health diagnosis, it’s recommended that I (or my child) not use AVE unless under the supervision of a qualified health care practitioner. And that if  I, or my child, are currently taking recreational drugs or participating in excessive alcohol consumption, it’s recommended that I (or my child) do not use AVE unless supervised by a qualified health care practitioner.

If I (or my child) have a heart pacemaker, CES, (Cranial Electro Stimulation) should NOT be used. The electrical signals may cause the pacemaker to malfunction, leading to serious injury or death. Also, do not use it if you have epilepsy, brain tumors, or a recent stroke.

Further, I, or parent/guardian, am aware that the AVE programs are designed to stimulate activity in the brain (blood flow, glucose metabolism, and electrical activity) and that an individual’s dosage of medication (if applicable) should be monitored by her/his physician to prevent over stimulation.  

I understand that Audio Visual Entrainment (AVE) is a personal electronic device and is not medical or pharmaceutical. Any questions or concerns about an individual’s health should be addressed to the prospective individual’s physician.  The individual should continue any present ongoing therapies until otherwise advised by his or her physician.

By signing this form, I agree that I am satisfied with the information I have been provided (verbal, written or otherwise) by my clinician on the effects I can expect using the AVE brain training device. My questions have been answered to my satisfaction. I understand that everybody responds differently to brain training. Because of this, we can not predict how I (or my child) will respond. Results vary per person as do the the number of sessions required to meet personal goals. I agree to discuss with my clinician any concerns that I may have or that arise. I understand there are no recommended number of sessions required, and I may stop brain training at any time. Consequently, I agree to not hold Mind Alive® and A Chance To Grow responsible for a less than desired outcome or any outcome that may be considered negative.

I further agree that the any data obtained in connection with brain training may be used to further the research into the benefits of AVE brain training through future publications and presentations of results, with protection of the privacy and preservation of the anonymity of the participant.  

Whether participating in clinic with an AVE brain training session or at home using a purchased AVE system, I have read and understand the above consent and give permission for myself (and/or child) to have the opportunity to participate in the AVE brain training program. This consent is valid for the term of one year from the date signed below.