Registration Information Form

Please call 855-WHY-REMIND or provide your information below, and a member of our medical staff will be in contact to complete your registration.

Don’t let financial concerns keep you from taking action. Taking steps toward improving your cognitive health if you are already experiencing memory issues or reducing your risk for Alzheimer’s disease shouldn’t have to wait. We have financing available to help you get started immediately.

    • Participant Information

      Please complete the following information for the person experiencing symptoms of dementia:

    • Companion Information

      Please complete the following information for the companion of the participant:


  • Disclosure, Acknowledgement and Waiver


    Disclosure:

    RE:mind is an educational program focused on lifestyle management based on available scientific research in the field of Alzheimer’s disease and other forms of dementias or cognitive decline. One component of the program is to deliver a personalized protocol/plan for each participant to incorporate into their overall health care in coordination with their regular health care provider(s). The program also provides follow-up professional support for participants.

    Our goal for the RE:mind program is to offer you:

    • Empowerment
    • Scientific and cognitive health knowledge
    • Advocacy and Support

    What you can expect:

    • Learn how  biologic factors and genetics influence Alzheimer’s disease and cognitive impairment
    • Learn how nutrition plays a role in cognitive health
    • Learn which foods are recommended for maximizing brain health, and which foods should be avoided
    • Understand how exercise and proper sleep play a role in your brain health
    • Receive a personalized lifestyle protocol recommended for you based on your personal history, genetics, and biologic factors
    • Learn how to reduce stress through exercise, meditation, sleep and other activities

    What you cannot expect:

    • Although our providers will talk with you about medical information, we will not diagnose or assume oversight of the treatment of any illness or medical condition.
    • We provide scientific information and protocols based on scientific information but we cannot guarantee that the information or protocol will result in a particular outcome or change in your health.
    • Scientific information is changing all of the time, so we cannot assure that the information provided to you will not differ from currently available scientific information as it changes over the course of time.
    • AFFIRMATIVhealth has brought together other experts in science and medicine, including The Buck Institute, Sonoma Valley Hospital, Muses Labs, and others, to deliver certain portions of the information, activities, and materials in the program.  AFFIRMATIVhealth is not responsible for the information, actions or inactions of these parties.
    • Although we retain copies of the Muses Lab report and notes of our affiliated physicians or other providers taken while discussing your test results, we do not retain your overall medical records or assume responsibility for your overall medical care.
    • Any information or recommendations provided to you about your health should be discussed with your own physician or other health care provider to ensure that the recommendations are appropriate in the context of your overall health care and in combination with your current medications and medical treatments.

    I am 18 years of age or older, and I have entirely read the above, and I am capable of understanding the terms herein. Therefore:


    Acknowledgement:

    I acknowledge what I can and cannot expect from Re:mind as set forth above.

    I acknowledge that AFFIRMATIVhealth is not responsible for the acts of third parties who participate in the RE:mind Program.

    I acknowledge that except for physicians’ notes regarding discussion of Muses Lab test results and other providers notes taken during one-on-one sessions, AFFIRMATIVhealth does not retain medical records of protected patient information.


    Release and Waiver:

    I hereby release, hold harmless and indemnify, on behalf of myself and my heirs, AFFIRMATIVhealth, its owners, officer, directors, contractors, agents and employees from any and all causes of action, claim or liability on account of damage to property or person, including death, that may arise out of my participation in the RE:mind program, from whatever cause.


    Refunds

    In the event of an unforeseen circumstance that changes your ability to attend your scheduled RE:Mind retreat, AFFIRMATIVhealth will make every effort to reschedule you for a future retreat date. However, refunds are not able to be issued.


  • Consent for Access to and Review of Genetic Testing

    YYou have authorized genetic testing by 23andMe and the creation of a report by Muses Labs using the resulting 23andMe testing data. Testing for genetic conditions can be complex. AFFIRMATIVhealth understands you have or will have consented to genetic testing by 23andMe and Muses Labs. AFFIRMATIVhealth will review the results of certain components of these genetic tests and reports with you.

    By signing below, you hereby consent to AFFIRMATIVhealth’s access to and review of the genetic testing data and report referenced above. AFFIRMATIVhealth will discuss with you the results of the testing data and the report in the context of the RE:mind program. Further:

    • A positive result is an indication that you may be predisposed to or have the specific disease or condition. Further testing may be needed to confirm the diagnosis. You should discuss the results with your regular physician or a genetic counselor.
    • There is a chance that you will have a particular genetic condition but that the genetic test results will be negative. Due to limitations in technology and incomplete knowledge of genes, some changes in DNA or protein products that cause disease may not be detected by the test.
    • There may be a possibility that the laboratory findings will be uninterpretable or of unknown significance. In rare circumstances findings may be suggestive of a condition different than the diagnosis that was originally considered.
    • In many cases a genetic test directly detects an abnormality. Molecular testing may detect a change in the DNA (mutation) or extra, missing, or rearranged genetic material. Most of these tests are highly sensitive and specific, but the sensitivity and specificity may vary for certain abnormalities.
    • Because of the complexity of genetic testing and the important implications of the test results, AFFIRMATIVhealth will provide a physician, genetic counselor, or other qualified health care provider to discuss any results provided to you and to answer any questions you have about the results. The results are confidential to the extent allowed by law. The results will be released to a health care provider that you have indicated to receive the Muses Labs protocol report, but will not be released to other medical professionals or other parties without your written consent or as otherwise allowed by law. Participating in genetic testing is completely voluntary. You should consult with your healthcare provider about the test results.