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Polarity Therapy Appointment Request

Please fill out the following form to request an appointment. 
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    Peaceful Remedies is happy to be offering complimentary Polarity Therapy sessions to anyone diagnosed with a life altering condition AND primary caregivers.  

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    Polarity Therapy Program Eligibility Guidelines:

    1.    People with a life altering medical diagnosis and primary caregivers are eligible for            Polarity Therapy sessions. 

    2.    Six sessions are complimentary per client per year. Any sessions after that are at the cost of the client. 

    3.    Polarity Therapy sessions are 60 minutes in length. 

    4.    If you do not feel well or have any symptoms that may be Covid related the day of           your appointment, please reschedule your appointment.  

    5.   If you are unable to keep your scheduled appointment, please notify Peaceful                 Remedies 24 hours before the appointment time info@PeacefulRemediesOswego.com.

     

     

     

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    Photography and Video Release and Opt-Out Policy

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    General Waiver

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    I confirm and agree to the following terms and conditions:

    PEACEFUL REMEDIES, INC. WAIVER, RELEASE and INDEMNIFICATION FORM For myself, my executors, administrators, heirs, next of kin, successors and assigns. 


    I HEREBY: 


    Waive and release any and all claims that I may have against Peaceful Remedies, Inc. their board members, employees, staff, volunteers, agents and any one or more of them or their executors, administrators, heirs, next of kin, successors and assigns ("the releases") including any and all claims for damage caused by the negligence of any of them, arising out of my participation in any and all events, services, programs and its related activities, together with any costs including lawyers' fees that may be incurred as a result of any such claim whether valid or not. 

    Indemnify and hold harmless the releasees and each of them against any such claim that I or my executor, administrator, heirs, next of kin, successors and assigns may have or assert and against any costs including lawyers' fees with respect thereto. 

    I hereby acknowledge that participation in Peaceful Remedies, Inc. events, services, programs and its related activities carries  with it potential hazards. I therefore release Peaceful Remedies, Inc., their board members, employees, staff, volunteers, agents and sponsors of any liability resulting from injury or death during related activities. 

    I, the undersigned, hereby represent and agree for myself, my heirs, assigns, executors and administration as follows:


    I am in good physical health or have received a doctor’s permission to participate in my chosen event, service, program and related activities.

    I acknowledge the contagious nature of the Coronavirus/COVID-19.

    I further acknowledge that Peaceful Remedies, Inc., its board members, employees, staff, volunteers, agents cannot guarantee that I will not become infected with any contagious disease, including but not limited to, the Coronavirus/Covid-19. 

    I voluntarily seek services provided by Peaceful Remedies, Inc. and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19 and other contagious diseases. I acknowledge that I must comply with all set procedures to reduce the spread while attending a Peaceful Remedies, Inc. activity. 

    I hereby release and agree to hold Peaceful Remedies, Inc. harmless from, and waive on behalf of myself, my heirs, assigns, executors, administration and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of Peaceful Remedies, Inc. or that may otherwise arise in any way in connection with any services received from Peaceful Remedies, Inc. 

    I understand that this release discharges Peaceful Remedies, Inc. from any liability or claim that I, my heirs, or any personal representatives may have with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Peaceful Remedies, Inc.. This liability waiver and release extends to participants and all those associated with Peaceful Remedies, Inc.

    This release extends to every event, service, program, activity attended. 

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  • 23

    Please sign below if you agree with the photography and video release and opt out policy, and the terms and conditions stated on the Peaceful Remedies waiver releasing indemnification form.

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    ***Use computer mouse to sign. Hold down left mouse button and use mouse to write signature.
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