Name First Last Date MM slash DD slash YYYY PhoneConsent(Required) INTELLIGENT BIOENERGETICS, INC., DEMONSTRATION RELEASE AND DISCLAIMERNTELLIGENT BIOENERGETICS, INC., DEMONSTRATION RELEASE AND DISCLAIMER The undersigned recipient has requested a demonstration of the Electro-Proscope 360TM and/or Equine Proscope 360TM microcurrent instruments (“Instruments”) given by Intelligent Bioenergetics, Inc. (IntellBioTM). Recipient is aware that in order to demonstrate the Instruments and to understand how to operate them properly, probes or plates will be placed on various parts of the recipient’s body. Recipient understands and acknowledges that the Instruments are Class II medical devices that can only be used in conjunction with a licensed healthcare professional (“LHP”). If the practitioner/technician is not an LHP in his or her state of residence, it will be necessary for him or her to associate with an LHP in order to operate the Instruments in compliance with the law. Further, the Recipient acknowledges that Intelligent Bioenergetics, Inc. does not make any medical claims regarding the Instruments. The use of the Instruments by a trained operator is not a medical treatment and is not intended to diagnose, treat, cure, or prevent any disease. The Recipient specifically releases and holds harmless Intelligent Bioenergetics, Inc., its officers, directors, employees, technicians, and agents, from any claims or causes of action relating to the Instruments and their use or relating to any of the training and information provided by Intelligent Bioenergetics, Inc. Recipient understands that the current charge for each session with the Instruments is $____________ per session (approximately 1 hour in length). By signing this document, the Recipient affirmatively states that he or she has none of the following conditions: 1. A demand pacemaker or any other type of pacemaker in his or her body; and 2. She is not pregnant; and 3. He or she has no existing physical, mental, or medical conditions, such as heart, which would be triggered or exacerbated by a session with the Instruments; and 4. He or she acknowledges that he or she has an affirmative duty to inform the Thorp Institute and its technicians of any such conditions prior to be considered for a demonstration; and 5. He or she fully accepts the demonstration at his or her own risk. Recipient is 21 years or older and has read, understood, and accepted the provisions of this agreement. Any persons under the age of 21 must have their legal guardian sign on their behalf.