stocktonpsychiatry.com - Hearing Aid Form

Hearing Protection Requirement Waiver
Name:
DOB:

MonthDayYear
Date
I, First Name Last Name ,have been informed that it is recommended to wear ear plugs during TMS therapy treatment to protect my hearing. I choose to not wear hearing protection and will hold harmless, MBM Inc. its employees, physicians, affiliates, and agents in the event of an adverse effect due to my decision. I understand that it is my choice to not wear hearing protection and I must sign this waiver whether I choose to wear or decline ear plugs.
Patient Signature

Clear
Date

MonthDayYear
Date
Witness Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Hearing Protection Requirement Waiver