Background: I desire to be tested to determine possible undesirable reactions
to various stressors that are natural constituents of my diet, environment or body chemistry. I understand that the device being used is FDA cleared for Galvanic Skin Response Testing and not intended to directly treat or cure any specific condition, symptom or illness
Procedures: I understand that this is a non-invasive procedure (the skin is not pierced). Homeopathic remedies, nutritional supplements and other natural remedies may be used to bring abnormal electrical patterns into equilibrium.
Risks: The procedure is very safe because it measures only changes in the electrical properties of the skin. Skin irritation or redness may occur at the site of the test. However, any discomfort should be brief. There are generally no risks associated with the substances recommended to bring your body to equilibrium as long as those substances are taken as recommended. Please report any significant health problems (i.e. diabetes, high blood pressure, etc.) to your examiner. I agree to seek immediate medical attention and understand that this facility does not treat cases of patients suffering from anaphylactic allergic reactions, during pregnancy, neoplasm or cancer, or who have pacemakers, or defibrillators, and I agree to completely disclose all information regarding any life threatening allergies or allergies resulting in anaphylaxis, as well as any of the above prior to undergoing these procedures.
Payment of Services: You are responsible for the payment of the normal and necessary fees associated with the assessment and services performed as a result of that testing, if purchased in this clinic.
I have read and understand the above information and my rights. I consent to the use of clinical reports and results of my case for study, the purpose of advancing clinical knowledge, research and scientific purposes provided that my identity is kept confidential.