HEART SOUND RECORDER

Patient Consent & Patient Survey Forms

Instructions ** You MUST complete both prior to appointment **

1. READ the PATIENT CONSENT below, then click the button to submit your consent

2. Click the button below to complete the PATIENT SURVEY

Patient Consent

I give Smeeta's trained Heart Sound Monitor practitioners permission to record the sound of my heart and to create a graph of that sound on the Heart Sound Recorder (a general wellness cardiac stress monitor). I have been informed and understand that the Heart Sound Recorder is not an electrocardiograph like those in hospitals or physicians and that it is not capable of diagnosing heart conditions and is not in any way a substitute for such a device. I further understand that the Heart Sound Recorder has not been reviewed or cleared by the US Food and Drug Administration. I understand that if I have or believe I have a heart condition, that I should see a physician qualified to evaluate and treat that condition.

Any suggested nutritional or dietary advice is not intended as treatment or therapy for any disease or symptom of disease. Nutritional counseling, supplement recommendations, and exercise considerations provided to me are to support the normal physiological processes of the body.

I understand that any techniques, treatments, or lifestyle changes suggested after the use of this device should be undertaken only with the guidance of a licensed physician, therapist, or healthcare practitioner. The findings from this device can be used to support, but should not be used in place of sound medical therapies and recommendations.

I am giving permission to Smeeta's trained Heart Sound Monitor practitioners to share my graph with other practitioners for educational purposes only so long as my name and other personal information are removed.

By signing below, I agree to the above.

Patient Consent Form

Consent

Name

By typing your name below, you are signing this form electronically.

First Name

Last Name