CONSENT - HOMEOPATHIC PROTOCOL NDA - Private Study (non-clinical, non-medical)

You are agreeing to a non-medical, non-clinical case study.

The U.S. Food and Drug Administration (FDA) has not approved or cleared this test. However, FDA approval or clearance is not required to use the test for this consent.

312-236-7010

PATIENT FIRST NAME

PATIENT LAST NAME

PATIENT DATE OF BIRTH

PATIENT EMAIL ADDESS

PATIENT PHONE #1

PATIENT PHONE #2

MAILING ADDRESS

* Be sure this is accurate for mailing purposes. Please include number, street, city, state, zip and country *

YOUR CURRENT OCCUPATION

NAME OF YOUR EMPLOYER

YOUR EDUCATION LEVEL

IF YES, WHAT ARE THEIR AGES?

WHO SHOULD WE CONTACT IN CASE OF AN EMERGENCY?

PLEASE LIST NAME, PHONE NUMBER AND EMAIL ADDRESS

PLEASE LIST ALL COVID-19 VACCINATIONS RECEIVED AND DATE ADMINISTERED.

If NONE type NA

PLEASE LIST YOUR MOST CONCERNING HEALTH PROBLEMS AT THIS TIME?

YOUR CHIEF COMPLAINTS

WHEN DID YOUR CHIEF PROBLEM OR ILLNESS BEGIN?

WHAT DO YOU BELIEVE MAY HAVE CAUSED YOUR CHIEF COMPLAINT?

HAVE YOU CONTRACTED COVID 19 IN THE PAST? IF YES, WHAT DATES?

HAVE YOU BEEN VACCINATED WITH THE COVID 19 VACCINE? IF YES, PLEASE LIST BRAND AND DATES

SURGICAL HISTORY

PLEASE LIST ANY SURGICAL PROCEDURES YOU HAVE HAD AND APPROXIMATE DATE.

MEDICAL HISTORY

PLEASE LIST ANY SERIOUS MEDICAL CONDITIONS FOR WHICH YOU HAVE BEEN TREATED OR HOSPITALIZED IN THE PAST WITH APPROXIMATE DATES.

PLEASE CHECK IF YOU CURRENTLY HAVE ANY OF THE FOLLOWING?

PLEASE CHECK IF YOU HAVE OR HAD ANY OF THE FOLLOWING HEALTH ISSUES:

AGE YOUR MENSTRUATION BEGAN?

HOW FREQUENT ARE YOUR MENSTRUAL CYCLES?

EVERY ____ DAYS

HOW LONG DOES YOUR CYCLE USUALLY LAST?

____ DAYS

NUMBER OF PREGNANCIES

NUMBER OF BIRTHS

NUMBER OF MISCARRIAGES

NUMBER OF ABORTIONS

PLEASE LIST ANY SPECIFIC FEARS THAT YOU HAVE.

I hereby acknowledge and confirm that I have agreed to participate in this private; non-medical, non-clinical study using a Homeopathic, non-allopathic treatment approach.

The information I have provided is accurate to the best of my knowledge.

I understand this is a privately funded homeopathic study which is non-clinical and non-medical and has not been approved nor evaluated by the FDA.

The plan for this study has been fully explained to me and I do not hold the investigators or Dr. Alan Bain, DO responsible or accountable for my decision to participate in this study. I understand that my results may be shared with other investigators and doctors taking part in this study with Dr. Alan Bain, DO.

I am here on my own behalf and not as an agent for federal or local regulatory agencies or associations and I am not seeking information under cover for false identity or misrepresentation of my situation or on a mission of entrapment. Further, I have agreed to proceed with the treatment plan of my own accord without promise or assurance of the efficacy of the study treatment.

HOMEOPATHIC PROTOCOL: I understand the protocol fee is $200 USD which includes 2 rounds (8 weeks) of homeopathic protocol. I understand this is a non-medical , non-allopathic approach with homeopathic ultra dilute non-material therapy. This is not a clinical or medical trial.

NON - ALLOPATHIC APPROACH: I understand this is a non-medical , non-allopathic approach with homeopathic ultra dilute non-material therapy. There is not guarantee this protocol will cure or alleviate your symptoms. This is not a clinical or medical trial.

CONSULTATION FEE: I understand a consultation is required prior to beginning the protocol. Consultation fee with Dr. Alan F. Bain, D.O. - $227 USD. Follow up visit fees - $127 USD

REFUND/RETURNS: I understand that there are no refunds, returns or exchanges allowed for this protocol once the protocl has been shipped.

GENERAL STUDY ENROLLMENT: I understand this study group is PRIVATE and consists of multiple investigators and doctors along with Dr. Bain. I wish to enroll in this general study and agree to not discuss or disclose my results or information publicly outside of this study group. This is not a clinical or medical trial.

I understand I may remove myself from this private study at any time by sending a written request to the office via mail: 444 N Northwest Hwy, ste 200, Park Ridge, IL 60068 or by email: Patientservices@docintheloop.com

WHAT IS YOUR REASON FOR JOINING THIS STUDY?

A consult with Dr. Bain is required prior to beginning this protocol.

CONSULTATION

I already had a consult with Dr. Bain

I have NOT had a consult with Dr. Bain and need to schedule an appointment.

Typed Signature

By typing your name above, you acknowledge this is your legal binding signature.

Date

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CONSENT - HOMEOPATHIC PROTOCOL NDA

You are agreeing to a non-medical, non-clinical case study.

You are agreeing to a non-medical, non-clinical case study.

Dr. Alan F. Bain, DO

Internal Medicine