CONSENT TO YOGA THERAPY TREATMENT

I am voluntarily enjoining Yoga Therapy with Soundness With Sayde. I hereby request and consent to the performance of yoga therapy treatments and other procedures within the scope of the practice of yoga therapy.  I can view the scope HERE. Treatments, including assessments and technique guidance, are solely for me (or on the patient named below, for whom I am legally responsible) by the yoga therapist indicated above and/or other licensed therapists who now or in the future treat me while employed by, working or associated with, or serving as back-up for the yoga therapist named above, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.

I understand that I am the decision maker for my health care.  Part of this office’s role is to provide me with information to assist me in making informed choices.  This process is often referred to as “informed consent” and involves my understanding and agreement regarding the care recommended, the benefits and risks associated with the care, alternatives, and the potential effect on my health if I choose not to receive the care.  I further understand that altering medications or other therapies without first consulting my personal physician or health care provider is not recommend.  Yoga therapy is not intended to substitute for other diagnosis or treatment by medical doctors and other health care providers nor to be used as an alternative to necessary medical care.

I understand that methods of treatment may include, but are not limited to:

• asana (movement)
• physical cuing
• mindfulness
• meditation
• guided visualization
• pranayama (breathing exercises)
• mudra (energetic gestures and seals)
• bandha (energy locks)
• mantra (sacred sounds)
• sankalpa (affirmation/intention)
• education in yoga philosophy
• lifestyle reflection
• listening

with optional touching or positioning of the body by the therapist. If I do not wish to be touched, I will notify the Yoga Therapist, so that a joint decision can be made about where it is appropriate to continue the practice with that limitation.  I will immediately notify a member of the clinical staff of any unanticipated or unpleasant response to the therapies. 

 

I appreciate that it is not possible to consider every possible complication to care.  I have been informed that the work is done together and is a generally safe method of treatment, but, as with all types of healthcare interventions, there are some risks to care, including, but not limited to:  dizziness or fainting; numbness or tingling; nausea, gas, stomach ache; headache; changes in sleep patterns; changes in bowel patterns. 

While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that, as with all healthcare approaches, results are not guaranteed, and there is no promise to cure.

I understand that I must inform, and continue to fully inform, this office of any medical history, family history, medications, and/or supplements being taken currently (prescription and over-the-counter). This includes pregnancy or attempts to become pregnant. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent.

I understand that preventative measures intend to reduce the spread of infections among the person(s) participating in the therapy, including influenza, rotovirus and COVID-19.  As this work can involve physical proximity over an extended period of time, with shared materials, in a closed space, there may be an elevated risk of disease transmission.  I acknowledge and assume the risk of becoming infected with infection, including COVID-19, through this treatment.  I proceed with permission for care of myself and care for others by avoiding attendance if I experience:

• a fever of 99.9 or greater
• respiratory or flu symptoms, sore throat, shortness of breath
• chills, muscle aches, new rashes or lesions
• new loss of taste or smell
• exposure to large groups of people or person(s) diagnosed with such symptoms.

I acknowledge the risk infections in the community space and with community props. I intend this consent to cover the entire course of care.

I voluntarily assume all risks inherent in the nature of yoga therapy treatments and services.  I waive all claims, costs, liabilities, expenses and judgments against Soundness With Sayde, their trustees, officers, agents representatives, and employees from all claims, costs, liabilities, expenses, and judgments arising out of treatments and services.  I understand that I have the right to a second opinion and to secure other options about my circumstances and healthcare as I see fit.

By voluntarily signing below, I  confirm that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of yoga therapy, and have had an opportunity to ask questions.  I agree with the current or future recommendations for care. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment with the below listed yoga therapist or colleagues.