Red Light Pain Relief Intake Form

Please take a moment to fill out our online intake form before your visit. All information is kept completely confidential.

Informed Consent & Release of Liability Agreement
Program and Background
The purpose of this Informed Consent & Release of Liability Agreement (“Agreement”) is to inform you of the nature of this Treatment, its intended benefits, and potential risks. By signing this Agreement, you are acknowledging that you have requested treatment utilizing LipoMelt LED light therapy (the “Treatment”) from Fuel Physical Therapy & Sports Performance, LLC
(“Fuel PT”) under the terms and conditions described in this Agreement. The Treatment involves the application of a 635nm and 880nm light. Any medical or cosmetic treatment carries the potential for risks, complications and varied results.

Treatment Process
Initially you will consult with a LipoMelt therapist to determine if you are a candidate for the LED therapy treatment. You will have the opportunity to ask questions or voice concerns you may have regarding this Treatment. If it is determined you are a suitable candidate, then paperwork, measurements, pre and post treatment photos (upon your approval) and suggested course of treatment will be given. The Treatment is administered by placing up to 6 LED pads on the desired area(s) to be treated or via the Trifecta Full Body Bed System (Pro 300). Most patients will need a minimum of 9 – 12 treatments for the Light LED therapy to achieve its desired effect. This Treatment should be used in conjunction with a healthy diet and exercise. You should consult a health care professional before beginning any new exercise program to determine if your body is physically able.

Risks/Discomfort
This Treatment is non-invasive. During Treatment there should be no discomfort. The client may feel the warmth of the light. In some cases, there may be redness, swelling, heat sensitivity, pain or discomfort, and/or increased bowel movements and urination. LipoMelt is suitable for anyone over 18 who does not have any of the following issues: Pregnancy; Breast Feeding; Recent Cancer; Heart Disease; Pacemaker or Metal Pins or Plates (“Prior Condition”). By signing this Agreement, you confirm that you are over 18 years old and do not have a Prior Condition.

Intended Benefits; No Guarantee of Results
The intended benefit and cosmetic indications for this Treatment include body contouring, lymphatic drainage, cellulite reduction, skin tightening and skin rejuvenation, pain relief, inflammation treatment, neuropathy relief, and treatment of problem fat areas without surgery. Increased redness to the area for up to 12 hours may be experienced (although this is unlikely). Normal activities may be resumed following the Treatment. Any problem areas or excess pockets of fat can be targeted, however, the most commonly treated areas are the stomach, hips, flanks, and thighs. You understand that there are many factors that may impact the results achieved through this LED light therapy Treatment, including many that are outside of the control of Fuel PT, such as your diet, nutrition and exercise habits, sleep, water consumption, metabolism, genetic makeup, and other individual medical, environmental, and lifestyle factors. You accept, agree, and understand that Fuel PT cannot and does not promise or guarantee any particular results from this Treatment. You also understand that any testimonials or endorsements by other clients or audience on the Fuel PT website, sales pages, or other content have not been scientifically evaluated by Fuel PT and the results experienced by individuals may vary significantly. Any statements outlined on the Fuel PT website, content, or offerings are opinions and are not guarantees or promises of actual performance or results. You have been informed of the potential risks and side effects of Treatment including, but not limited to, redness, swelling, heat sensitivity, pain, increase bowel movements and increased urination. The risks, potential damages and adverse side effects have been explained to you and you fully understand them.
Each body is different and may require more or less Treatments depending on your diet, exercise, metabolism and body type. You understand the treatment is most successful if you also maintain a healthy diet and commit to an exercise program.
You understand that no guarantee has been given as to the results that may be obtained by this Treatment. You have read this Agreement and certify that you understand its contents in full. You have had enough time to consider the information and feel you are sufficiently advised to consent to this Treatment. You hereby give your consent to have this Treatment. If at any time during the Treatment you experience pain or discomfort of any kind, you agree to inform the staff immediately and/or terminate the session at your discretion.
You hereby authorize technicians to perform the Treatment for the purpose of body contouring, lymphatic drainage, improvement of cellulite and skin tightening. You are aware that clinical results may vary depending on individual factors, medical history, patient compliance with
pre/post treatment instructions, and individual response to treatment.

Release of Liability
You understand that you are voluntarily undergoing the treatment and that it is your voluntary and informed decision to participate, regardless of any associated risks or dangers. You expressly release and forever discharge and hold Fuel PT, it’s staff, members, managers, agents, and representatives harmless from any and all liability, claims, lawsuits, demands, or causes of action whatsoever arising out of any damage, loss, or personal injury incurred while participating in the treatment.
You agree that you have reviewed this consent form and your consent and authorization for this Treatment are strictly voluntary. By signing this Agreement, you grant authority to perform the described treatment and attest that the purpose of the Treatment, its risks, complications, and alternative methods of treatment have been fully explained to your satisfaction.

Media Consent
You authorize Fuel PT to take and use images to show your progress and agree that these photographs may be used for the purpose of publication, promotion, illustration, advertising, or marketing in any manner or medium. You understand that you may revoke this consent at any time by informing Fuel PT in writing of your desire to do so.

Questions and Explanations 
By signing this Agreement, you certify that this Treatment has been explained to you and that you have been fully informed of the nature and purpose of the Treatment, expected outcomes and possible complications, and understand that no guarantee can be given as to the final results obtained. You are aware that Treatment may cause slight hypo/hyper–pigmentation of the skin and treatment is taken at your own risk (tattoo areas should be avoided). Any further questions can be directed to a LipoMelt Specialist. Furthermore, you confirm you are of lawful age and legally competent to sign this Agreement, and that you are signing this document of your own free will.

Whole Body Vibration Plate Exercise Risks
Whole Body Vibration Plate Machines are scientifically calibrated exercise machines designed to force your muscles to stretch and contract rapidly in small increments, replicating the same action which occurs during traditional exercising. Vibration exercises use your body weight and gravity to its fullest potential. Please do not use a whole body vibration plate or any other exercise device without getting approval from your doctor.
The device is not recommended if you are: pregnant, diabetic with complications such as neuropathy or retinal damage, have a pacemaker, recently underwent surgery, suffer from epilepsy or migraines, have herniated disks, spondylolisthesis, spondylolysis, have cancer or tumors, have recent joint replacements, have metal pins or plates, or have any other concerns about your physical health. These contra-indications do not mean that you are not able to use a vibration or other exercise device, but it is recommended that you consult your physician first. You understand that using a whole body vibration machine workout is a strictly voluntary physical activity. If at any time you experience pain or discomfort of any kind, you agree to inform the staff immediately and/or terminate the exercise.

Privacy Policy
We value your privacy and are committed to maintaining your security and confidentiality in the use of any information you choose to share with us. We do not disclose identifiable information to any third party without your consent. Further, we do not sell, rent, or otherwise allow the unauthorized outside use of personal information such as names, addresses, phone numbers, or e-mail addresses in our database without your permission. Copies of this form and signature will be valid as if original if this document is digitally scanned.

HIPAA Notice: Endwell Chiropractic & Pure Esthetics

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Please review it carefully.

"We": refers to Endwell Chiropractic and/or Pure Esthetics. "You" or "yours" refers to any individual receiving treatment by Endwell Chiropractic and/or Pure Esthetics employees. Federal law - means the Health Insurance Portability and Accountability Act and related privacy rules - requires Endwell Chiropractic and/or Pure Esthetics to keep your health information private. We are not allowed to use or disclose it unless we receive your permission or unless permitted by law. Federal law requires us to give you this Notice of our legal duties and privacy practices. This Notice is to inform you of uses and disclosures of your health information that we may make. It also informs you of your rights and our duties with regard to this health information.

We must follow the terms of this Notice. We do reserve the right to change the terms of this Notice and make the new Notice provisions apply to all the health information we keep. This includes health information we had prior to any change in this Notice We must promptly change this Notice when there is a material change to our uses or disclosures, your rights, our duties, and other related circumstances. To receive such Notices by email, you should tell the contact listed at the end of this Notice.

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Federal law permits us to use and disclose protected health information for purposes of treatment, payment and healthcare operations as those terms are defined under federal law. We will comply with any state or federal law that is more restrictive as to our uses and disclosures of protected health information.

There are also times when federal law permits or requires us to use or disclose your information without your written permission. Additionally, where appropriate, we may disclose protected health information to a group health plan or plan sponsor in accordance with federal law. Permitted Disclosures:

We may not make all of the uses and disclosures listed here, but federal law permits use or disclosure of your information without your permission.

-When we disclose your information to you.

-To third party non-Endwell Chiropractic and/or Pure Esthetics associates that perform services for us or on our behalf.

-Where disclosure is required by law.

-To a public health authority authorized by law to collect or receive your information to prevent or control disease, injury or disability or when reviewing reports of child abuse or for the conduct of other authorized public health activities and responsibilities.

-To a health oversight agency for such activities.

-For judicial and administrative proceedings.

-To a law enforcement official for a law enforcement purpose.

-To a medical examiner for the purpose of identifying a deceased person, determining the cause of death, or other duties authorized by law.

-To organ donor organizations in order to aid in such donations.

-For certain research purposes authorized by and subject to federal law. - To avert a serious threat to health or safety.

-To government officials regarding military personnel and certain domestic and foreign government officials for certain functions authorized by federal law.

-To comply with workers' compensation and other similar programs.

Required Disclosures

We must disclose your information when required by the Secretary of the Department of Health and Human Services to make sure we comply with federal law. We are also required, with certain exceptions, to provide you with access to inspect and obtain a copy of your information that we keep See "Federal Law Provides You with the Right to Inspect and Copy Protected Health Information" below.

INDIVIDUAL RIGHTS WITH RESPECT TO YOUR PROTECTED HEALTH INFORMATION FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO REQUEST RESTRICTIONS:

You have the right to request restrictions be placed on certain uses and disclosures of your information. We are not required to agree. If we do agree, we may not use or disclose any of your information except where you need emergency treatment. We may end an agreement to restrict as allowed by federal law. If you wish additional information, you should write to the contact listed at the end of this Notice.

FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO ALTERNATIVE CONFIDENTIAL COMMUNICATION OF PROTECTED HEALTH INFORMATION: If you choose to have your information sent to you by means of your choice or to an address of your choice, we will do so if the request is reasonable. You must clearly state that disclosure of all or any part of your information could endanger you if not sent per your choice. Any such request should be sent in writing to the contact listed at the end of this Notice.

FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO INSPECT AND COPY PROTECTED HEALTH INFORMATION: You have the right to inspect and copy your information, certain information relating to civil, criminal, or administrative proceedings, and certain information prohibited by law from disclosure. Any request should be sent in writing to the contact listed at the end of this Notice. If you wish additional information, you should write to the contact listed at the end of this Notice.

FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO A PAPER COPY OF THIS NOTICE: You have the right, even if you have agreed to receive notice by email, to get a paper copy of this Notice. All requests should be in writing and sent to the contact listed at the end of this Notice.

FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO FILE A COMPLAINT. If you believe your privacy rights have been violated, you have the right to complain to us by writing to the contact listed at the end of this Notice. Federal law prohibits retaliation against you for filing such a complaint. The contact listed at the end of this Notice is also available to provide you information regarding questions you have or other information concerning this Notice.

THE CONTACT TO WHOM YOU SHOULD ADDRESS YOUR COMPLAINT IS:

Endwell Chiropractic and/or Pure Esthetics

Email Address: endwellchiropractic@gmail.com or pureestheticsny@gmail.com

Cancellation Policy:

We require a cancellation notice at least 24 hours in advance of your reserved session. You acknowledge that if you cancel within 24 hours of a reserved session, you will still be charged the full amount of your session. If you fail to show up or are more than 5 minutes late for your session, you will lose or forfeit your session due to staff wages and fees paid for my session, Our cancellation policy has been created to ensure that our loyal clients are not disturbed by the tardiness of clients who do not show up on time, or who cancel within 24 hours of an appointment When reserved sessions are unattended, this means that loyal clients missed the opportunity of having that particular time period.

Purchase and Reservation Policy:

Sessions will only be confirmed and allowed up to the amount of pre-paid sessions. All sales are final and non-refundable. We reserve the right to terminate any client’s session, package, or contract, without refunding any monies if the client has broken any terms or policies. All purchases are final, non-refundable and non-transferable.
*You understand and agree that if you have purchased and pre-paid for a first-time customer promotion, you may not use or purchase another first-time promotion without our prior consent.

General Provisions:

This Agreement shall be governed and construed in accordance with the laws of the State of Michigan, without reference to rules regarding conflicts of laws. Any dispute arising out of this Agreement shall be submitted to a state or federal court sitting in Grand Rapids, Michigan, which shall have the exclusive jurisdiction regarding the dispute and to which court's jurisdiction the parties irrevocably submit.

If any court of competent jurisdiction finds any provision of this Agreement to be invalid or unenforceable, such provision shall be interpreted to the maximum extent to which it is valid and enforceable, all as determined by such court in such action, and the remaining provisions of this Agreement shall, nevertheless, continue in full force and effect without being impaired or invalidated in any way.

This Agreement may be amended only by a written instrument signed by each of the parties. A waiver of any right under any provision of this Agreement by either party shall be valid only if such waiver is in writing and signed by the party to be charged. No waiver of any right under any provision of this Agreement on any occasion shall be a waiver of any other right or under any other provision or on any other occasion.

This Agreement constitutes the entire understanding and agreement between the parties with respect to the subject matter of this Agreement and supersedes any and all prior or contemporaneous oral or written communications, all of which are merged in this Agreement. Neither party is relying on any warranties, representations, assurances, or inducements not expressly set forth in this Agreement.

Disclaimer For Our Services:

At Endwell Chiropractic and/or Pure Esthetics we’re in the business of creating real results NOT setting unrealistic expectations for our patients. For this reason, we require ALL PATIENTS to have before and after photos taken while on one of our custom-tailored programs. By signing this form, the patient (YOU) understands that these pictures will not be displayed publicly without additional consent and will be used for internal referencing, notes, and to help ensure that the patient (YOU) get long lasting results without starving yourself or going through surgery.
By signing this form, you agree that you will not receive any form of financial compensation and refusal to consent to in-office photos will not affect the care or treatment plan that you receive; however, we highly encourage everyone to participate.
In addition, we request all patients mandatorily sign this agreement to commit themselves to our program. Our goal with patients is to help others live healthy, fun, and confident lives and we ask for 100% effort from our patients throughout the length of our program. Failure to complete or comply with the program’s guidelines will not entitle the patient to a refund.