benderchiro.com - Brain Tap

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Informed Consent for BrainTap Sessions
Introduction

At Bender Chiropractic Health & Vitality Center, we offer BrainTap sessions designed to help you achieve mental clarity, relaxation, and improved neurological functioning through a combination of guided visualization, binaural beats, and other relaxation techniques.

Procedure Description
BrainTap is a high-tech relaxation session that uses a headset to deliver gentle light pulses that travel through the retina and ear meridians. The sessions are combined with meditative audio to encourage mental and emotional stress relief, brainwave entrainment, and relaxation. Each session lasts approximately 15-30 minutes, depending on the selected program.

Potential Benefits
The benefits of BrainTap sessions may include:
- Reduced stress and anxiety
- Enhanced sleep quality
- Improved cognitive function and focus
- Increased energy levels
- Greater emotional stability
Potential Risks
The risks associated with BrainTap sessions are minimal but may include discomfort from the headset, light sensitivity for those prone to migraines, and transient disorientation immediately after the session.

Voluntary Participation
Your participation in BrainTap sessions is entirely voluntary, and you are free to discontinue at any time.

Confidentiality
All information disclosed within sessions and the written records pertaining to those sessions are confidential and will not be shared without your written consent, except where the disclosure is required by law.

Acknowledgment and Consent
By signing this form, I acknowledge that I have read and understood the information provided about BrainTap sessions. I have had the opportunity to ask questions, and any questions I have asked have been answered to my satisfaction. I consent to participate in BrainTap sessions under the terms described herein.
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Notice of Privacy Practices Acknowledgement

Initial Uses Authorization Form
Effective: 4-15-2003

By signing this form, you acknowledge that you were presented with a copy of the Notice of Privacy Practices of Bender Chiropractic Health and Vitality Center. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full.

Our Notice of Privacy Practices is subject to change. The most current Notice of Privacy Practices will be placed on display in the office at all times. You may obtain additional copies of our most current notice by requesting it from our privacy official, Dr. William L. Bender

Bender Chiropractic Health and Vitality Center also uses protected health information for the following reasons: (you may opt out of this authorization). Marketing; internal referral board, testimonials, pictures on bulletin board, or information unrelated to healthcare and other marketing materials. (please initial to give us authorization)
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If you have any questions regarding this notice or our health information privacy policies, please contact:
Dr. William L. Bender

You can reach the Privacy Official at: Bender Chiropractic Health and Vitality Center, 33580 Harper Avenue, Clinton Township, MI, 1-586-738-6833
Hours Available: A message may be left for our privacy official any time the clinic is open and your call will be returned within 7 business days.
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Intake Form

Informed Consent for BrainTap Sessions

Notice of Privacy Practices Acknowledgement