1. Nature of Risk
Transcranial Magnetic Stimulation (TMS), specifically BrainsWay Deep TMS, involves the delivery of pulsed magnetic fields to the brain. A primary safety concern with TMS is the potential for an induced seizure.
The use of illicit drugs including cocaine during the course of a TMS treatment series creates an unpredictable and hazardous environment that significantly increases the risk of a grand mal seizure or other adverse neurological events.
2. Patient Representation and Disclosure
By signing this document, I acknowledge and agree to the following:
- Mandatory Disclosure: I agree to provide a full and honest disclosure of any substance use, including cocaine, to the clinical staff prior to every treatment session.
- Active Use: I understand that if I have used illicit drugs within 72 hours of a scheduled session, I must inform the technician immediately.
- Consequences of Non-Disclosure: I understand that withholding information regarding drug use use puts my physical health at extreme risk.
3. Assumption of Risk
I freely and voluntarily assume all risks associated with undergoing BrainsWay TMS treatment while having illicit drugs in my system. I recognize that the clinical staff and Evolve Psychiatry cannot guarantee my safety if I am under the influence of or withdrawing from illicit stimulants.
4. Full Release of Liability
In consideration for the treatment provided, I, on behalf of myself and my heirs, hereby release, waive, and discharge Evolve Psychiatry, its owners, directors, officers, employees (including TMS technicians), and the manufacturers of the equipment (BrainsWay) from any and all liability, claims, or causes of action including those arising out of:
- Any seizure or medical emergency occurring during or after treatment related to my use of cocaine.
- Any long-term neurological or physical complications resulting from the interaction between TMS and illicit substances.
- Any injury sustained due to my failure to disclose substance use.
Patient Affirmation: I have read this document and fully understand that I am taking 100% responsibility for any adverse events that occur if I choose to use cocaine during my TMS treatment course.