I, the undersigned intended Recipient of alternative therapies, am of sound mind and age. I have read this Consent Form and information relevant to alternative and restorative medicine and their respective modalities of oxygen therapy, ozone therapy, vitamin and mineral therapy, food allergy testing and oxidative medicine (collectively “Alternative Therapies”).
I understand, acknowledge and I admit that these Alternative Therapies are not therapies in the traditional medical curricula of the U.S.A, and that the phrase “alternative therapy” in the context of the consent hereby given does not import or carry any legal significance with me but rather are intended to define or characterize these modalities of therapy as being unconventional and alternative modalities of therapy not necessarily approved by FDA for any particular use or
purpose.
The Q Institute, the administrator of the alternative therapies has informed me that these Alternative Therapies have not been through vigorous clinical testing and that there is no scientific peer evidence to suggest that they work for any particular purpose and that some types of unapproved therapy may not be completely safe and could in fact cause harmful side effects.
I admit that I have not been coerced into giving my consent, nor have I been unduly influenced, manipulated, or promised a particular outcome. Any hoped-for outcome as may be occasioned by my usage of said Alternative Therapies have been fully evaluated against potential of personal bodily harm or side effects any of which I voluntarily and fully accept without reservation.
All my questions related to the Alternative Therapies have been answered to my satisfaction and I have either corroborated the answers with professional third-party(s) or I voluntarily waived my right to do so, and in any event I voluntarily and fully accept any/all risks as may be occasioned by my decision to give my consent hereby and use the Alternative Therapies and I am aware that usage is completely voluntary. I realize that I may decide to refuse usage or stop usage at any time.
I hereby, for myself, my heirs, executors, administrators, assigns or personal representatives, knowingly and voluntarily waiver and release liability and hereby relinquish and waive any and all rights, claims or causes of action of any kind whatsoever arising out of my usage, and do hereby release and forever discharge the Q Institute, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors or assigns for any
physical or psychological injury, including but not limited to illness, paralysis, death, damages, economical or emotional loss, that I may suffer as a direct result of any usage. I understand and agree that The Q Institute may release the relevant personal information about me upon order of a court of competent jurisdiction. I understand that I am entitled to access the personal information collected about me and to have inaccuracies corrected.