Consultation Agreement Nature of work performed: Infrared Regulation Thermography (IR2T) IR2T is a whole-body test that uses an infrared sensor to measure skin temperature at over 100 points in the body before and after a brief cooling period. This mild stress stimulus induces the body’s function of thermal regulation through the ANS’ control of blood circulation to the skin. An automated software program, based on data from 30+ years of use in 500+ medical centers worldwide. Analyzes the thermal responses, providing insights into the physiological, functioning health of various systems of the body. Cost of Thermography Consultation: I agree to pay $290 for the thermography scan. Rights and Responsibilities: Sima Ash of Healing 4 Soul agrees to honor confidentiality and assures professional conduct and privacy regulations. Sima also agrees to elicit a history of indications relevant to my condition and discuss the results with me accordingly, I hereby acknowledge and retain the service of Thermography at Healing 4 Soul and in order to maximize the benefits received from this diagnostic screening, I agree to provide a summary of medical and non-medical health care services which I have sought or am now considering, along with a complete description of my health history and current conditions. This agreement becomes part of my case records and Healing 4 Soul has the right to terminate treatment at any time. Patient Name(*) Invalid Input Date of Birth(*) Invalid Input Patient Signature(*) Invalid Input Email Address Invalid Input I Agree(*) By typing your name you are agreeing to the above term Invalid Input Verification(*) Invalid Input