NASHVILLE NEURO PSYCHIATRIC ASSOCIATES
Consent for Quantitative Electroencephalography (qEEG)
Client / Guarantor Responsibility:
Iunderstand that this procedure has been recommended by Dr. Clark and hereby
consent to the qEEG data to be collected and shared with an outside consultant (Minnesota Neuro-Training Institute) for purposes of analysis and recommendations. I willingly assume responsibility for all charges for services rendered and agree to
adhere to payment policies. Cost of qEEG: $1200. Repeat qEEG: $800.
I hereby authorize my individual provider to release any all information regarding patient
care to my insurance company, if requested.