Lymphatic Drainage Client Treatment Consent and Release
I understand that the Post Operative Manual Lymphatic Drainage (Post Op MLD) I receive is provided for the basic purpose of improving the flow of my lymphatic system and also for relaxation and reielf of pain, and swelling. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I also understand that practitioners are not guaranteeing any certain or specific result with the supportive modality.
I further understand Post Op MLD should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see my treating physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that my Post Op MLD practitioner is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.
Because Post Op Lymphatic Drainage/Bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.
*Please Note: Manual Lymphatic Drainage (MLD) is a very powerful modality and certain medical conditions are contraindicated and determine if and when you can receive a session. After the consultation and review of the information you have provided, it will be determined if MLD should be administered to you. Some conditions will require a note from your doctor before proceeding. Please understand this is for your safety and well-being.
Photo Release and Video Release
I hereby absolutely and irrevocably authorize Adaptiv Wellness as well as their legal representatives, assignees, and transferees to use, publish, reuse, republish, distribute, disseminate or otherwise make publicly available for any artistic or commercial use, including advertising, publication, or illustration images of me (NO public use of photos will display client's face) and/or my property, of the following description:
taken in whole or in part, whether individually or collectively with any other material, in any and all forms of media now or hereinafter known and/or developed, including, but not limited to, in print media, in digital media, on the Internet, in composite images, or distorted images or for any other lawful use as may be determined by Adaptiv Wellness. The artist shall specifically be permitted to use fictitious names in conjunction with the images.
I further completely release and discharge Adaptiv Wellness from any and all demands or claims that may arise out of or otherwise be connected with the use of the photographs and video featuring me, my image or my property, including, without limitation, and any all claims for the violation of a right of publicity, a right of privacy, or libel. I also waive any and all rights to approve or otherwise review any uses of the photographs and video featuring me, my image or my property.
This authorization and release shall inure to the benefit of the legal representatives,licensees, heirs and assignees of Adaptiv Wellness and shall also be binding upon me, my heirs, assignees, and legal representatives.
Payment: Initial in office appointments require payment in full.
Payments are non refundable. Deposits and payments may be transferred as a credit to a future surgery date.
For Post Op and/or Private Nursing Packages: Clients are required to pay a 25% of the package total as a deposit. Deposits are transferable but non refundable other than in the case of surgery being cancelled by the surgeon. Package is non refundable once services are initiated and must be used within one year from serivice inititiation.
Late Policy: Each session is up to one hour. Clients are allowed a 15 minutes grace period for arrival to each session. Kindly notify the practitioner if you are running late. Session length will be adjusted when clients arrive late, even if within the 15 minute grace period.
Arriving more than 20 minutes late, failure to cancel a previously scheduled apointment prior to 24 hours before the appointment start time and any no call no shows, will result in client being charged the full amount of the appointment, or if client has a package, one appointment will be deducted from the package, no make up appointment will be allowed.
The client's signature below indicates full understanding of the above terms. The clients also that their signature below indicates agreement to forever hold harmless and release Adaptiv Wellness and their contractors from any and all liability, claims, or demands of any kind or nature related to the transmission of any disease, condition or illness they may allege to have contracted or been exposed to as the result of any treatment, person, or visit at the insured's location.