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 Sessions I may have a feeling of soreness in my nose and throat for several days. My nose may drain for several days after treatment I 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