Pediatric QbTesting Consent Form

This form is intended for kids and teens (less than 18 years old) who are NOT a patient of Dr Nerissa Bauer's practice.

QbTesting is conducted at 12735 Meeting House Rd, Suite 200, Carmel, IN 46032 in the Village of West Clay.

Child/Teen Name

First NameLast Name

Child/Teen Date of Birth*

Child Sex*

Parent/Guardian Name

First NameLast Name

Parent/ Guardian Phone Number

Area CodePhone Number

Parent/Guardian Email

example@example.com

Family Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Child/Teen Primary Care Physician *

Primary Care Provider Clinic Name*

Phone Number of Primary Care Physician*

Please describe reason for seeking QbTesting (e.g. symptoms, risk factors, whether on medicine and feeling like it is not working etc.)

Has your child/teen been formally diagnosed with ADHD by a physician, psychologist or other certified mental health provider?

YesNot yet but suspected or we have concerns

Is your child currently on medication for ADHD?

Yes (if yes, please bring the medicine or write down the name and strength and bring with you to the appointment)No

How did you hear about QbTests with Dr Nerissa Bauer?

If you child is on medication for ADHD, many times doctors want to have the Qb Test done to check medication efficacy. Therefore, please make sure to schedule the test when you know that the medicine is still in your child's system. We highly recommend to make sure your child takes the medicine as they would. If your child is on any stimulant medication for ADHD (e.g. Adderall XR, Concerta, Vyvanse, Jornay, Azstarys, etc) please make sure the test is scheduled at least an hour after your child takes the medicine to ensure it is active and also before 230pm to ensure we are testing the medicine towards peak and not as it is wearing off as it can skew interpretation.

Make sure to check with the referring provider whether he/she wants you to meet with Dr Bauer to review the test results (separate 30-minute appointment and an additional $150) OR if the referring provider will meet with you after they get the interpretation report from Dr. Bauer

The referring provider feels comfortable reviewing the results with me so just send the interpretation reportThe referring provider does NOT feel comfortable reviewing the results with me so I will need to meet separately with Dr Bauer (30 minute appointment to be scheduled AFTER the QbTest is done)I am not sure and will check with the referring provider and I will email Dr Bauer at drnerissabauer@gmail.com or send a message through CHARM

Notice that Dr. Nerissa Bauer is a behavioral pediatrician and ADHD Specialist for Children/Teens.

This single visit does not constitute or establish a doctor-patient relationship. There is no follow up provided after the ADHD Computerized Testing and it is expected and understood by both parties that the parent/guardian will complete all appropriate medical follow up, including sharing the QBTest report, with their child's/teen's primary care physician or mental health specialist such as a psychiatrist of their choosing. There will be no follow up visits after this testing appointment unless recommended by the referring provider.

Dr. Bauer will not make an official diagnosis based on results obtained after testing given the request is for testing only. The diagnosis of ADHD requires additional history taking and other potential workup based on medical and family history, parent and teacher ratings and observations that your child's/teen's primary care doctor or specialist may want after seeing the QBTest results. If your child or teen's primary care provider does not feel comfortable managing ADHD you may wish to email with Dr Bauer about whether she can do a consultation (drnerissabauer@gmail.com) after the testing or she can provide you with a referral.

What to expect:

The total cost of testing plus a report back to the referring provider will cost $185 and payment is due upon conclusion of the testing. You will get a superbill PDF and receipt in the BILLING tab of CHARM that you can download and submit for claim to your insurance provider.

You will get an email from Dr Bauer with instructions on how to activate the CHARM PORTAL which will allow you to select an appointment time.

Testing will take appropriate 20 minutes but plan on 45 minutes in the office with our QbTest technician, Amy Barnes.

Once the consent form is completed, you will get an email from Dr. Nerissa Bauer with instructions on next steps.

**IF THE REFERRING PROVIDER WANTS DR BAUER TO REVIEW THE TEST RESULTS WITH YOU there will be a separate charge of $150 for the 30 minute appointment to meet with Dr. Bauer. Otherwise Dr Bauer will just create the interpretation report and send to the referring provider who will then review the results and do any further diagnostic interview.**

Signature

Date Signed*

Date

Medical Consent Form