Thyroid Cranial Health Form

Thermal imaging is a technology which measures the surface temperature of the body using infrared cameras and is analyzed to provide physiological information as an adjunct to standard screening and diagnostic testing.

I understand that thermal imaging does not and cannot directly detect or be used to diagnose injury or disease of any kind and that the information is designed to be used with other examinations as an aid to the diagnostic process. Nor can it rule out the presence of injury or disease since some conditions do not produce sufficient temperature changes at the surface of the body to be seen with thermography. Therefore, injury or disease may still be present despite a lack of thermal findings present on examination. All concerns require evaluation by a doctor regardless of the thermal imaging results. Use of thermography as a stand-alone detection examination is not recommended as it can result in the failure of an existing condition to be detected.

I further understand that not all dental, thyroid, and other conditions of the head and neck will produce thermal findings that will enable detection. Therefore I understand that this test cannot determine if these structures are diseased or healthy and it cannot diagnose disease. It is a functional test which may provide general regions to evaluate more thoroughly by a health care provider. It cannot replace or rule out the need for examination or additional testing.

I confirm that I have followed the written pre-examination protocols for thermal imaging provided to me before the examination. I understand that if I did not receive and follow these protocols, the accuracy of my examination may be compromised.

By signing below, I hereby acknowledge that (1) I have read and understood each of the above paragraphs; (2) I have had an opportunity to ask any questions I may have had; (3) any questions I asked were answered to my satisfaction; (4) I have received sufficient information with respect to thermal imaging to make an informed decision to undergo the procedure; (5) I understand no guarantee or warranty is being made that all risk for current and/or future cancer will be detected; and (6) I hereby authorize and consent to thermal imaging

I understand and agree that Robert L. Kane, D.C., D.A.B.C.T., dba Kane Thermal Imaging Interpretive Services (collectively referred to as "Kane Interpretive Services") is a California based company that contracts with the provider of your imaging services solely for the purpose of interpreting and reporting thermal imaging scans. Your provider is not an employee, officer, director, partner, representative or agent of Kane Interpretive Services. Nor is Kane Interpretive Services an employee, officer, director, partner, representative or agent of your provider. Kane Interpretive Services is a wholly separate business entity from your provider and does not oversee or supervise your provider's thermography operations. Kane Interpretive Services is not involved in the design, manufacture, marketing, sale, rental, distribution, installation, inspection, repair or modification of any machinery or products used by your provider. Rather, Kane Interpretive Services is an independent contractor hired by your provider solely to interpret thermal imaging data and to report the results. Kane Thermal Interpretive Services does not control, nor have the right to control, your provider's business, including its equipment, operations, advertising and/or representations. Kane Interpretive Services makes no promises, warranties or representations, express or implied, as to your provider's services. In addition, Kane Interpretive Services owes no duty of care to me in connection with provider's services, including no duty to screen provider, no duty to protect or warn me of any actions or inactions of provider and no duty to investigate, communicate or mitigate any risks, known or unknown, relating to provider's services. I assume all duty of reasonable care to select, screen and monitor provider's services for my own safety and protection. By signing this Statement of Independent Operations, I understand and agree with the foregoing and further agree that Dr. Robert L. Kane, D.C., D.A.B.C.T., dba Kane Thermal Imaging Interpretive Services is only responsible to me for the content of the thermal imaging report and its accompanying reporting guide.