Informed ConsentNBR is a manual therapy utilizing a balloon inflammation technique in the 6 sinus passages. The doctor has explained that the potential benefits are improved sinus breathing, better brain function/clarity of mind, and enhanced neural coordination of the body, but no guarantee of improvement is implied. I have been informed that the treatment is uncomfortable, but gets easier with each session.I have been informed that the NBR has been rigorously studied in a scientific manor, but has been discussed in the scientific journals, and has been utilized by chiropractors since the 1950’s as well as physical therapists & acupuncturists, and has been taught at Western States Chiropractic College.Procedure:During NBR balloon inflation, the balloon will be inflated for 2-3 seconds in each of the 6 sinus passages, often reaching the throat, and then will be deflated and removed quickly.During this 2-3 second period, a deep sense of pressure will build up in my sinus similar to diving into deep water, and will dissipate immediately when the balloon is deflated.During the NBA, I will likely hear a “crackling or popping” sound, my eyes may water, and I may sneeze or cough.I have been informed that occasionally the balloon may get stuck in the back of my throat and I may not be able to breath for a few seconds. In that eventuality, I have been instructed to remain calm and lay still with my mouth open as the doctor pops the balloon with a pin. This will take approximately 5-6 seconds.Treatment Risk:One recorded death occurred in 1980 where a down’s child breathing was blocked by the balloon and died. One other injury was recorded where the patient suffered a fracture in the nasal cavity from the treatment in 2002. No other serious injuries have been reported. Rarely, nosebleeds may occur.Contraindication: Bleeding disorders, blood thinning medications, current sinus infections, sinus surgery within the last year.General Considerations for Undergoing the NBRWithout limiting the generality of the foregoing, I am aware of the following facts regarding Nasal Balloon Release Procedures:I understand that a series of NBR is required to effectuate long term benefits.NBR does not replace a healthy diet, appropriate exercise, a toxin and pollution limiting lifestyle, or medical care.I understand I should not do NBR if I have any of the contraindications above, particularly bleeding disorders.After NBR SessionsI may have a feeling of soreness in my nose and throat for several days.My nose may drain for several days after treatmentI may have temporary aching or traveling pains in my head.I may feel disoriented.I may have an influenza or head cold sensation for a period of approximately three days.I may feel fatigued.I may feel excited, nervous, or euphoric which may interfere with my ability to sleep.I am also aware that I am in a temporarily fragile state for about a month after I receive NBR.This means that I may compromise the benefits of treatment with excessive stress.I will restrict my activities even though I may perceive having less pain.I will exercise mildly and regularly choosing bilaterally symmetrical activities.I will try to avoid activities that feature traumatic activities including jarring, hitting, and/or excessively fatiguing my body.I am aware that a patient's response to treatment may vary significantly from one patient to another, and acknowledge that there are no guarantees or assurances, and none have been made to me. I have had the opportunity to ask all questions that I desire, and have had my questions answered to my satisfaction. I understand the risks associated with NBR as set forth herein and outlined by the doctor, and I wish to proceed with NBR.Patient NameDate