INFORMED CONSENT FOR YOGA:
I understand that yoga includes physical movements as well as an opportunity for relaxation, stress re-education, and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from the instructor. I assume full responsibility for any and all injury, which may incur through my participation.
Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. By submitting this intake form and voluntarily participating in a yoga class, I affirm that a licensed physician has verified my good health and physical condition to participate in such a fitness program. In addition, I will make the instructor aware of any medical conditions or physical limitations before class. If I am pregnant, become pregnant or I am post-natal or post-surgical, I have verified with my physician and have approval to participate. I also affirm that I alone am responsible to decide whether to practice yoga and participation is at my own risk. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter to the yoga instructor.
I have read and fully understand and agree to the above terms of this Liability Waiver Agreement. By submitting the intake form and voluntarily participating in a yoga class will serve as my digital signature as complete and unconditional release of all liability to the greatest extent allowed by law in the State of New Jersey.
INFORMED CONSENT FOR MASSAGE THERAPY:
Microsoft Word - Intake Form.doc
It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. Massage therapy is given to me with the purposes of stress reduction, pain reduction, relief from muscle tension, increasing circulation, or a specific reasons stated in the intake form.
I understand that there is no implied or stated guarantee of success or effectiveness of individual techniques or series of appointments. I understand that massage therapy is not substitute for medical examinations or medical care, and that it is recommended that I work with my primary care provider for any and all conditions.
I understand that massage therapy does not diagnose illness or disease, or any other disorder, and that the massage therapist does not prescribe medical treatment or pharmaceuticals, nor are spinal manipulations part of massage therapy.
I have stated all my known medical conditions, medications, and I will inform my massage therapist of any updates or changes in my health status.
I hereby affirm that I have read and fully understand the above and agree to be legally bound by it.
I affirm that I am informed of my rights as a patient and that I consent to receive masage services by submitting this intake form and by scheduling my own massage appointment.
PRIVACY OF INFORMATION
The privacy of your personal information is important to our clinic. We are committed to collecting, using and disclosing personal information responsibly and only to the extent necessary for the goods and services we provide.
We collect, use and disclose personal information in order to serve our patients. The primary purpose for collecting personal information is to provide treatment.
We also collect, use and disclose information for purposes secondary to our primary purposes. The most common examples of our related and secondary purposes is to invoice patients for goods or services that was not paid for at the time, to process credit card payments or to collect unpaid accounts.
The cost of goods/services provided by the organization to patients is often paid for by third parties (e.g., motor vehicle accident insurance, private insurance). These third party payers often have the patient’s consent or legislative authority to direct us to collect and disclose certain information in order to demonstrate patient entitlement to this funding.
Patients or other individuals we deal with may have questions about our goods or services after they have been received. We retain patient information for a mandatory minimum of ten years after the last contact.
PROTECTING PERSONAL INFORMATION
We understand the importance of protecting personal information. For that reason, we have taken the following steps:
• Paper information is either under supervision or secured in restricted area.
• Electronic hardware is either under supervision or secure in a restricted area at all times.
• Paper information is transmitted through sealed, addressed envelopes or boxes by reputable companies.
• Electronic information is transmitted either through a direct line or has identifiers removed or is encrypted.
• External consultants and agencies with access to personal information must enter into privacy agreements with me.
YOU CAN LOOK AT YOUR INFORMATION
With only a few exceptions, you have the right to see what personal information we hold about you.
We can help you identify what records we might have about you. We will also try to help you understand any information you do not understand (e.g., short forms, technical language, etc.). We reserve the right to charge a nominal fee for such requests.