Patient Treatment Consent Form

Please read this document carefully. This consent form outlines the parameters, expectations, and disclosures associated with the Neuroregenesis treatment protocol overseen by Dr. Farshchian.

• •I like to receive therapy for my ailment by Dr. Farshchian on _______________ for treatment of neurological issues.
• •I watched the information and the videos. Based upon the advice given by Dr. Farshchian and my own judgment, I agree to be treated.
• •The doctor has explained the procedure to me and I agree to follow the instructions for self care after the procedure and to return for follow up care as recommended by Dr. Farshchian.
• •I understand just like any other medical procedure there are NO Guarantees and that this is not a cure and results vary from patient to patient. Medical center Addressed the risks, alternative options, and details about what to expect in the days and weeks after the procedure.
• •I understand that the medicines used are not reviewed by FDA and currently FDA has not approved them for neuroregenesis. And I understand the use of biologics in USA is still considered at experimental and research stage. Therefore, I agree to “right to try”.
• •I will call the office or answering service with any questions before the scheduled follow up visit.
• •I understand the maximum benefit of the therapy is best obtained if I do the program completely and follow the Dr.’s instructions.
• •This medical facility is not a Medicare provider; therefore Medicare will NOT reimburse you for this treatment. I understand that other private insurance companies may or may not reimburse for the procedure, however I am responsible to make payment upon service.
• •I confirm that I have disclosed my complete medical history, including all current medications, allergies, and pre-existing conditions, to the medical team.
• •I understand that the long-term effects of this experimental protocol are still under study, and I accept all associated risks.
• •I consent to the emergency administration of medical treatments or transfer to an acute care facility should any complications arise during the procedure.
• •I agree that any dispute or claim arising out of or relating to this treatment shall be resolved through binding arbitration.
• •I acknowledge that I am signing this agreement voluntarily, with full understanding of the contents, risks, and implications of the treatment.