CARRIE'S LAS COLINAS LYMPHATIC ROLLER CONSENT FORM

1. Description of Service

I understand that the service I am about to receive at Carrie's Pilates Las Colinas

consists of use of a lymphatic drainage roller system (a mechanical/motorized roller device) designed to promote lymphatic flow, circulation, and wellness. I understand this service is not a medical procedure, diagnosis, or treatment and does not substitute for evaluation or care by a licensed medical professional.

2. Acknowledgements and Assumptions of Risk

I hereby acknowledge and agree that:

I am voluntarily choosing to receive this service and understand that use of the roller device involves physical pressure, motion, and contact with my body.

I have disclosed all known medical conditions, surgeries, implants, pregnancy, or other health-related factors which might affect my safety with this service.

I have been advised to consult my physician or other qualified healthcare provider before participating if I have heart conditions, circulatory issues, lymphedema, recent surgery, infection, implants, pregnancy, or other serious health issues.

I recognize that despite best efforts, there are potential risks including (but not limited to) soreness, bruising, skin irritation, increased urination or drainage, temporary swelling changes, dizziness, discomfort, or other adverse effects.

I understand results may vary and no guarantee has been made regarding outcomes.

I will immediately inform the provider and cease participation if I feel any pain, discomfort, dizziness, or other adverse effect during the session.

3. Release, Waiver & Indemnity

In consideration of being permitted to use the lymphatic drainage roller system and services at Carrie's Pilates Las Colinas, I, for myself, my heirs, executors, administrators, and assigns, hereby:

Fully assume all risks of injury, damage or loss which may occur as a result of my participation in the service or use of the roller system (including risks caused by ordinary negligence of the business or its staff

Waive, release and discharge Carrie's Pilates Las Colinas, its owners, officers, employees, agents, contractors, successors and assigns ("Released Parties") from any and all claims, demands, causes of action, suits, liabilities, costs or expenses, including attorney's fees, arising from any injury, damage or loss I may sustain while participating in the service or use of the roller system, even if caused in whole or in part by the negligence of any of the Released Parties, except to the extent of gross negligence or willful misconduct under Texas law.

Agree to indemnify, defend and hold harmless the Released Parties from any claim brought by me or on my behalf or by others arising out of my participation in the service.

4. Certification & Voluntary Participation

I certify that I have read this document in its entirety, understand its contents, and have had the opportunity to ask questions and receive satisfactory answers. I understand that Texas law requires that the intent to release liability for negligence must be "clear and unambiguous" and that this document is conspicuous (titled "Release & Waiver of Liability", printed clearly, with distinct font or headings) to give me fair notice. I understand that by signing below I am giving up substantial rights including the right to sue the Released Parties under ordinary negligence. / am at least 18 years old (or if under 18 a parent/guardian will sign below) and am executing this agreement voluntarily.

If client is under 18 years old - Parent/Guardian

5. Additional Disclosures (optional but recommended)

List of disclosed medical conditions, medications, recent surgeries: