I understand that Bubbling Spring Wellness offers treatments using acupuncture; electro-dermal
screening, NeuroModulation Technique, BioSet allergy elimination
technique, applied kinesiology; herbal, homeopathic and nutritional
remedies, all of which are available to me as a patient of Daniel
I. Ebaugh, M.Ac., a licensed acupuncturist in the State of Maryland.
Acupuncture: The procedures and processes
used in acupuncture treatment have been fully explained to me and
I understand I may be treated with the insertion of needles, and
/or with the application of heat (moxa) to the skin. I further understand
that the Federal Government has deemed the use of Acupuncture "experimental"
as it is not yet a common practice in this country.
NeuroModulation Technique (NMT) is
an alternative non-invasive technique, which uses "Muscle Response
Testing" (MRT) to communicate with the Autonomic Control System
(ACS). As a computer programmer corrects "glitches" in computer
code, NMT corrects faults in the body's ACS, in order to move it
toward normal function. Each step of the NMT correction involves
muscle testing for ACS faults, and then delivering the appropriate
"query/ correction" script to reset the ACS for optimal function.
I have read Dr. Leslie Feinberg's article on the NMT process and I
understand that my practitioner has been trained in the Advanced NMT technique. I have not been promised success or
any specific results concerning treatment with this protocol.
A Remedy Search
is based on the fundamental principles of energetic medicine. Using
the latest computerized, biofeedback technology or Muscle Response
Testing to communicate with
the body's inner intelligence, we evaluate body functions from an energetic perspective.
Then we ask the body to tells us which remedies or combinations of
remedies are required to bring it back to balance. Dosage is
determined in the same manor.
I have read the following information pieces
written or edited by Daniel I. Ebaugh, M.Ac., L.Ac. "Classical
Acupuncture," "NeuroModulation Technique,
A Safe, Effective and Rapid Method of Restoring the Body's Inherent
Capacity to Heal," and "Eliminating Allergies
Without Drugs or Shots." All of my questions about these different
treatment modalities have been answered.
RISKS/SIDE EFFECTS I am aware Acupuncture
may result in certain side effects including local bruising, slight
bleeding, fainting, temporary pain or discomfort, and temporary
aggravation of symptoms existing prior to treatment.
NMT, BioSet, and Hormone Balancing are all
a non-invasive techniques and nothing is placed inside the body.
Therefore, the risk of side effects is minimal. However, during
the coarse of treatment, I understand it is possible that I might
experience certain typical detoxification symptoms such as fatigue,
digestive upset, headache, insomnia or restlessness. Additionally,
I understand, as a result of the healing process (Homeopathic Law
of Cure), my symptoms may get worse before they get better. If such
an aggravation of symptoms or detox reaction lasts more than 48
hours, I agree to contact my practitioner. Further, I agree that
my practitioner shall not be responsible for these or any other
side effects from the any of these treatments.
TREATMENT I herby voluntarily consent
to be treated with energy medicine in the form of Acupuncture, NMT,
BioSet, and/or Hormone Balancing as administered by Daniel I. Ebaugh,
M.Ac., L.Ac., an acupuncturist licensed in the State of Maryland.
I understand that other methods of testing and treatment for my
symptoms are available to me and I choose to be treated using these
nontraditional methods.
I desire to be muscle tested to determine
if, from an energetic perspective, there are faults operating within
my Autonomic Control System (ACS ) and if so, I want the ACS reset
for optimal function using NMT protocols.
I desire to be muscle tested and or Electro
Dermal Screened to determine if, from an energetic perspective,
my bodily functions are balanced or if I need
herbs and homeopathics.
I desire to be muscle tested to determine
possible undesirable reactions to various substances that are natural
constituents of my diet, environment or body chemistry.
I understand that neither muscle testing
nor Electro Dermal Screening has been scientifically proven to be
reliable and that my practitioner must still rely upon my observations
as to the efficacy of the test or treatment.
I am aware that if there is a worsening of
my ailment or condition or if it does not improve within the time
estimated by my practitioner at the beginning of treatment, I should
consult a licensed physician.
I understand that other methods of testing
and treatment for my symptoms are available to me and I choose to
be treated using the methods described above. Further, I understand
that (1) I may decline to participate in any of the above-mentioned
forms of treatment at any time; (2) I am free to stop taking the
recommended supplements/remedies at anytime; and (3) I can choose,
any time, to be treated with traditional Western medicine.
I have not been promised success or any specific
results concerning this treatment.
I understand that I am responsible for payment
of the normal and necessary fees associated with my tests, treatments,
nutritional supplements and remedies.
PRINT NAME OF PATIENT: _____________________________________________
SIGNED BY: __________________________________________________________
DATE: _______________________________________________________________
WITNESSES BY: _______________________________________________________
Bubbling Spring Wellness,
3930 Knowles Ave., Suite 301 Kensington, MD 20895
