Luxfest 2026 Wellness Lounge Consent
Please provide your contact information, symptom details, and consent to participate in wellness services.
Email
*
example@example.com
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Which of the following symptoms do you experience? (Check all that apply)
*
Poor Posture
Neck Pain
Upper Back Pain
Mid Back Pain
Low Back Pain
Shoulder Pain
Arm Pain and Numbness
Headaches
Tingling sensation in hands & fingers
Swelling in hands & wrists
Leg pain or numbness
Wrist Pain
Hip pain
Knee pain
Ankle Sprain
Foot Pain
Plantar Fasciitis
Fatigue / Lack of energy
Stress / Tension in shoulders
TMJ Pain
Migraines
Other
MUSCULOSKELETAL DEMO CONSENT & LIABILITY WAIVER
1. Nature of Services
I understand that the services provided by SF Custom Chiropractic at this event are brief wellness demonstrations, which may include soft tissue therapy, mobility work, and/or chiropractic techniques. These services are limited in scope, duration, and assessment, and are not intended to replace a full clinical evaluation, diagnosis, or treatment plan.
2. Not Medical Care
I understand that this interaction does not establish an ongoing doctor-patient relationship, and that no formal diagnosis or comprehensive examination is being performed. I have been advised to seek care from my personal healthcare provider for any ongoing or serious conditions.
3. Risks of Treatment
I understand that there are inherent risks associated with chiropractic care, manual therapy, and massage, including but not limited to: soreness, sprains, strains, fractures, disc injuries, dislocations, and, in rare cases, stroke or other complications.
4. Health Status Acknowledgment
I affirm that I do not have any known medical conditions that would prevent me from safely participating, or I have chosen to proceed at my own discretion. I understand it is my responsibility to inform the provider of any injuries, conditions, or concerns prior to receiving services.
5. Assumption of Risk & Release of Liability
I voluntarily consent to participate in these services and assume all risks associated. To the fullest extent permitted by law, I release and hold harmless SF Custom Chiropractic and its providers from any and all liability, claims, or damages arising from my participation.
6. Opportunity to Ask Questions
I acknowledge that I have had the opportunity to ask questions and have them answered to my satisfaction.
Type your name to acknowledge and agree to the above waiver
*
Consent to Treatment
*
I consent
I do not consent
HIPAA Compliance Form
*
I acknowledge that my information is protected under HIPAA.
Submit Consent
Should be Empty: