Neurofeedback Contract & Consent Form - Pay Pal Logo
  • Neurofeedback Rental Contract & Consent Form

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Care Instructions

    • Please do not stretch the cables. 
    • Please do not eat or drink near the system. 
    • Please keep the system away from pets.
    • The system is not waterproof or water resistant so please do not take near water sources or into saunas or spas. 
    • Please do not take any part of the machine into the bathroom or toilet.
    • Please either pack the system and it’s accessories away each time after use or keep it set up in a safe place in your home. 
    • Please follow supplied instructions at all times.
    • No more than two sessions per day is recommended for adults and no more than one for children.
    • It is your responsibility to give your brain adequate rest between sessions.
    • Please ensure the tablet is shut down correctly each time. 
    • Please preserve the battery by only plugging in while it is in use. 
    • The system provided does not have permission be used in a commercial capacity. 
  • Consent Agreement 

    I acknowledge & sign on behalf of all parties for all points listed below:

    • NeurOptimal® is not a medical treatment, device or methodology.
    • NeurOptimal® is not used to diagnose medical disorders nor is it used as a medical treatment for disorders and has not been approved for any medical purpose by the Australian Department of Health, FDA, Health Canada or any other governing agency.
    • While Zengar/NeurOptimal® trainers may or may not be licenced health care practitioners, their use of NeurOptimal® is solely as a tool for brain training and optimisation & not as a means of diagnosis or as medical intervention.
    • I am satisfied with the information I have been provided (verbal, written or otherwise) by my trainer, Gema Jackson, on the effects I can expect during my NeurOptimal® training and my questions have been answered to my satisfaction.
    • I understand that it is not possible to predict what my central nervous system will do with the information it is offered and consequently there can be no guarantee as to the results of my training.
    • I agree to cease training if I am less than happy with the results I am getting. I understand that NeurOptimal® is purely a source of information and does not direct the response of the central nervous system. Consequently, I agree to not hold Zengar Institute Inc or Clear Mind Space | Valor Pty Ltd | Neurofeedback Rentals or Gema Jackson responsible for a less than desired outcome or any outcome that may be considered negative.
    • I agree to relay this consent advice on to all parties who use the system and sign this on behalf of them also. 

  • Powered by Jotform SignClear
  • prevnext( X )
    4 Week Rental Product Image
    4 Week Rental
    $900AUD
      
    12 Week Rental Product Image
    12 Week Rental
    $2,000AUD
      
    52 Week Rental Product Image
    52 Week Rental
    $5,600AUD
      
    Free Add On - Focus Package Product Image
    Free Add On - Focus PackageThis free Add-On includes: Focus Workbook | Atomic Habits Book | Clear Mind Priming Tool | Pomodoro Timer
    $ FreeAUD
      
    Total
    $0.00AUD
  • Choose from one of the PayPal options to make your payment.

  • Should be Empty: