Studio X, LLC
dba Medicine Wheel Wellness
CONSENT FOR TREATMENT
CONSENT FOR TREATMENT: I hereby consent to recommended and/or performed examination & treatment that has been deemed necessary or desirable by personnel Medicine Wheel Wellness. I do not hold Medicine Wheel Wellness facilities or personnel responsible for any injury, condition or lack of progress that may be incurred throughout the care process.
RELEASE OF INFORMATION/PATIENT RIGHTS: I certify that the information given by me in requesting treatment, reporting symptoms or assigning payment is correct. I authorize and request Medicine Wheel Wellness to furnish and release any medical or personal information to be disclosed or used only to benefit my current injury/condition or to obtain payment if necessary. Under the services of Medicine Wheel Wellness, federal regulations protect my confidentiality and patients rights for non-discriminatory treatment by a licensed provider.
FINANCIAL AGREEMENT: I fully understand that I am financially responsible for all charges incurred. The undersigned agrees, whether signing as agent or as patient, to pay the account of Medicine Wheel Wellness in accordance with the regular rates and terms of the clinic. Should the account be referred to any attorney for collection, the undersigned shall pay reasonable attorney’s fees and collection expense incurred by the clinic. I may pay total balance due at any time without penalty or additional finance charge.
CANCELATION & NO SHOW POLICY: I agree to pay a 50% cancelation fee to Medicine Wheel Wellness if I do not call within 24 hours to cancel my scheduled appointment. If I do not show up to my appointment and have not called to cancel, the full fee of the appointment will be charged to my credit card on file. If I have purchased a package, my credit card will be charged according to the cancellation policy separate from the package. This is to ensure optimal scheduling availabilities for all of our patients. The undersigned certifies that they have read the foregoing, and is the patient, or is duly authorized by the patient as patient’s general agent to execute the above and accepts its terms.
ASSUMPTION OF RISK AGREEMENT AND WAIVER AND RELEASE
In consideration of the instruction, classes, education, advice, or other health and training services provided by independent contractors, agents, representatives and all other persons or entities associated with Medicine Wheel Wellness from time to time (“Collectively Medicine Wheel Wellness”), and as an express condition precedent to any participation in the direct services, appointments, activities, classes, and programs provided by Medicine Wheel Wellness, including, but not necessarily limited to, all direct booking services, fitness classes, programs, workshops, yoga, and the like, whether along or in conjunction with other, (collectively the “Services”).
I agree and acknowledge these as follows: Although Medicine Wheel Wellness has taken reasonable steps to provide me with appropriate service, instruction, guidance, and equipment, I am fully aware and acknowledge that the services and activities contain certain inherent foreseeable and unforeseeable risks, hazards and dangers, some, although, not all of which would include: terrain, weather, temperature, lack of hydration, my physical condition, physical exertion, equipment and actions of other people, and that these foreseeable and unforeseeable occurrences could cause me to experience damage to my property and/or injury to my person or loss of life (collectively, but without limitation, the “Risks”).
I understand and acknowledge that all of the Risks associated with the Services cannot be fully foreseen and, therefore, the Risks are just examples and are not interpreted by me to be an exhaustive list of all possible Risks, hazards and dangers associated with the Services .
I acknowledge that the staff of Medicine Wheel Wellness has been available to me to more fully explain the nature of the physical demands, and the Risks of the Services . Moreover, I recognize and am aware that Medicine Wheel Wellness cannot eliminate or reduce the Risks associated with such Services . I therefore agree to accept full responsibility for the Risks of the Services .
I further agree that my participation in the Services is purely voluntary and I elect to participate in the Services with fill knowledge of the Risks associated with the Services . I understand and acknowledge that the Services may require a degree of skill and knowledge different from other Services. Further, I affirmatively acknowledge that I wish to participate in the Services knowing and in spite of the Risks, and further affirmatively acknowledge and represent that it is my responsibility to manage the Risks I deem appropriate.
Furthermore, in taking responsibility for my own actions, including my decision to participate in Services , I hereby waive and release any and all claims, rights or causes of action, present or future whether known, anticipated or unanticipated, that I, my successors, heirs, or assigns, may have against Medicine Wheel Wellness resulting from or arising out of, or incident to, my participation in the Services, regardless or whether the claim or cause of action is based on the negligence of Medicine Wheel Wellness.
Furthermore, I agree to indemnify and hold Medicine Wheel Wellness harmless from any and all claims brought against Medicine Wheel Wellness. I understand that this is a legal and binding agreement and that I have been given the opportunity and recommendation that I consult with legal counsel prior to execution of this document. I further represent that I am of legal age and have carefully ready and fully understand this “Assumption of Risk Agreement and Waiver and Release”.
• Participant Under 18 Years of Age: In signing this agreement on behalf of a minor (less than 18 years of age) (“Child”), I represent that I am the parent and/or legal guardian of such Child. I acknowledge and agree that I have read the above agreement, and that by signing this agreement on behalf of Child, I and Child agree to be bound by it’s terms. I further understand and agree that it is my responsibility to fully inform Medicine Wheel Wellness of any specials needs Child may have.
-By signing this waiver, I do hereby also give my consent to have my photo/video used as part of Medicine Wheel Wellness's social media strategy, marketing, and promotion. If I do not wish to have my photo/video taken, I understand I must tell the instructor and/or photographer/videographer to not include me in any promotions.