Vibroacoustic Reiki Waiver

New Client Information and Waiver of Liability
Date*

MonthDayYear
Date
Name*

First NameLast Name
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Do you have any serious medical conditions or allergies?*
Emergency Contact Name*
Emergency Contact Phone*
Vibroacoustic Therapy provides a deep state of relaxation that stimulates blood flow through all of the body’s tissues, reduces stress hormone levels and releases natural endorphins. While generally considered safe, I am fully aware, as with any treatment there are risks and side effects.

I further understand that each individual may have a unique experience. I agree to take full responsibility for my thoughts and actions during my session and the waiver of liability and all agreements made herein shall apply to each and every therapy session moving forward.

The Mended Willow Vibroacoustic Reiki Therapy practitioners will not evaluate or diagnose any health conditions and I assume full responsibility for my choice to participate in Vibroacoustic Therapy.

I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against The Mended Willow, LLC and its employees and agents. I will not hold the owner/operator of The Mended Willow, LLC nor its employees and/or agents liable for any injury during a session or while on the premises.
To ensure a comfortable and safe Vibroacoustic Reiki experience, I agree to the following (Please check each statement below to show you will abide by the conditions set forth):*

Minors are not permitted to participate in Vibroacoustic Reiki Therapy. I certify that I am at least 18 years old.I am not pregnant.I have no pacemaker or any other battery operated implanted device.I do not suffer from active bleeding.I have not had an organ transplant.I do not suffer from Hypotension (very low blood pressure).I do not have Deep Vein Thrombosis (VAT could dislodge a clot).I agree that, if I smoke, I will refrain from doing so for at least one hour prior to entering the center to avoid brining the odor of smoke into the therapy room or bed.I have not had any recent surgery and/or open wound (VAT affects circulation and can reduce necessary blood clotting while healing).I do not suffer from any bleeding disorders.I do not suffer from any seizure disorders.I do not suffer from Acute Rheumatoid Arthritis.I do not suffer from Hypertonia.I do not suffer from acute inflammatory conditions.I do not suffer from psychosis or any other severe mental disorders.I am not under the influence of any medication, drug or alcohol.
** If it is found that any of the preceding conditions were agreed to untruthfully and/or were not adhered to, The Mended Willow, LLC reserves the right to cancel an appointment without a refund or to ask a guest to reschedule.
The Mended Willow - Cancelation and No Show Policy

Cancellations must be made more than 24 hours before the appointment time. Cancellations made less than 24 hours before the appointment time will result in a 50% charge of the original appointment fee being charged to the card on file. No call or no shows will result in the full charge for the original appointment being charged to the card on file.

By agreeing to the statement below you are acknowledging and understand you could be responsible and charged for any damages caused during your visit or for any cancelled or skipped appoinments per the poilicies outlined above.
The Mended Willow - Credit Card on File

Due to the nature of our business we require our customers to keep a credit or debit card on file. Your card information is stored securely in our system and no charges are assessed until the day of your scheduled appointment. You may pay with cash or a different method during your visit in lieu of the card on file.
Credit Card Authorization(Please check the statement below to show you will abide by the conditions set forth):*

I authorize The Mended Willow to charge my credit card for agreed upon services. I understand that my information will be saved to file for future transactions on my account. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.
I understand that:

· The Mended Willow, LLC reserves the right to refuse service to anyone.

· I am choosing to use Vibroacoustic Reiki Therapy of my own free well and will not hold the owner/operator or The Mended Willow, LLC liable for any injury during a session or while on the premises.

· No one has made any representations or claims to me of any treatment or cure of any disease or condition; or any promise of any specific or general results of any kind.

·        This signed document represents an agreement between us, which you may revoke in writing at any time.

Only a trained medical professional can provide diagnoses or give medical advice. When it comes to your health or specific medical concerns you should always consult with a trusted medical physician. They can assess your circumstances and provide accurate information regarding any potential risks or interations related to vibrocoustic therapy and your specific needs.

I have read and fully understand and agree to the above terms of this liability waiver agreement. I am signing this agreement voluntarily and recognize my signature serves as complete and unconditional release of all liability to the greatest extent allowed by law in the State of Pennsylvania. By signing below you agree that you have read it in its entirety and fully understand The Mended Willow, LLC waiver and release form.
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New Client Information and Waiver of Liability