Release/Waier/Indemnity and Requirements Agreement
DISCLAIMER AND RELEASE AND WAIVER OF LIABILTIY AND INDEMNITY AGREEMENT FOR BIOENERGETIC SCAN by Rita Panahi, L.Ac./Rita Panahi
This agreement is entered into between Rita Panahi/Rita Panahi, L.Ac., and client who confirms his/her agreement to all of the provisions shown below by agreeing to a BioEnergetic Scan appointment and lifestyle consulting with Rita Panahi/Rita Panahi, L.Ac..
The Qest4 BioEnergetic Scanning System provides a completely non-invasive method for gaining valuable information about your body’s vital functions. The primary objective of the screening is to disclose patterns of stress and provide feedback that will assist in developing a program to restore each system and meridian to balance.
As part of this agreement, Rita Panahi/Rita Panahi, L.Ac., does not promise or guarantee protection from future illness. The BioEnergetic Scan is considered an alternative procedure and is not a substitute for medical care. Advice offered is designed to give information for energetic imbalances within the body. Advice offered is not designed to be a diagnosis or cure of any disease, injury or medical condition past, present or future, but as an added support. The consulting suggestions should be done in conjunction with ongoing medical treatment and evaluation and not take the place of any treatment.
- I understand that the Qest4 Bio Energetic screening will only identify energetic imbalances and does not diagnose any disease in the body. The Balancing Item refers to energetic frequency needed to restore balance to the body. Balancing Items are defined differently from medical terms and are not a cure for any disease.
- I understand that the Qest4 survey does not provide medical diagnosis and that my testing technician may recommend further medical testing. If I suspect I need further medical intervention, I understand I should consult my physician (PCP/specialist). I give my permission for the testing technician to evaluate me on the BioEnergetic Scan and that the scan will give me information about myself on an energetic basis. I understand that the scan will not pass judgments on prescribed medications and it is the responsibility of my primary care physician to make any adjustments on prescribed medications. Any decision to follow through with the recommended program is my own decision and I hold the testing technician Rita Panahi/Rita Panahi, L.Ac. harmless.
- I understand that I am here to learn about natural health and better lifestyle practices and I will be offered information about food, supplements and herbs as a guide to general health. The intent is to provide educational information for the purpose of assisting with lifestyle changes necessary to regain and maintain an environment needed to produce a healthy balanced body.
- I understand that I should continue to see any medical doctors I am currently under the care of, and that any prescribed medication should not be altered without first consulting the physician who prescribed it.
- I fully understand that I am not here for any medical diagnostic purposes. Information about the traditional uses of supplements that may create a healthy balance in the body may be discussed. This is not intended to be interpreted as a substitute for a licensed physician’s treatment. Nothing said, done, typed, printed, or reproduced through the BioEnergetic Scan by Rita Panahi, L.Ac./Rita Panahi is intended to diagnose, prescribe, treat, or take the place of a licensed physician. There is no obligation to purchase any supplements.
- I am not on this visit, or any subsequent visit, acting as an agent for the federal, state, county, local law enforcement or news media on a mission of entrapment or investigation.
- I understand that all information and conversations will be kept confidential, and that information concerning myself can be released to another health professional only with my written consent.
- I recognize that the Qest4 BioEnergetic screening is an alternative approach to balancing my health. Being of sound mind, I have chosen this screening to assist in balancing my health of my own free will and in exercise of my constitutional right for the attainment of life, liberty, and the pursuit of happiness.
In consideration of their participation in the consulting sessions, the client hereby accepts all risk to client’s health, including the risk of injury or risk of death that may result from such participation and client releases and waives all claims against Rita Panahi/Rita Panahi, L.Ac., and her employees, representatives, estate, heirs, next of kin, and assigns staff (collectively, the Releasees) from the consulting sessions.
The client further hereby agrees to indemnify and hold harmless Rita Panahi/Rita Panahi, L.Ac., and the Releasees from any and all loss, liability, damage to property, injury or death of any person(s) and/or costs court costs, attorneys fees that may incur that relate to or involve in any way the consulting sessions in which he/she participated, regardless of the cause of such damage and/or injury. The client acknowledges that he/she, as the client, is fully responsible for their health and well-being as well as that of their family (where applicable) and releases Rita Panahi/Rita Panahi, L.Ac. and the Releasees from all damage or injury. The client assumes all risks of the consulting, whether or not such risks were created or exacerbated by the consulting.
The client releases Rita Panahi/Rita Panahi, L.Ac., and the Releasees from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law, admiralty or equity, arising from the client’s past or future participation with respect to the consulting.
CHOICE OF LAW, ARBITRATION AND LIMITED REMEDIES
This agreement shall be construed according to the laws of the State of California only no matter where the client resides. This agreement is valid worldwide. In the event that any provision of this Agreement is deemed unenforceable, the remaining portions of the Agreement shall be severed and remain in full force. In the event a dispute arises between the parties, the client agrees to arbitration alone being the form of resolution and the parties will submit to binding arbitration before the American Arbitration Association (Commercial Arbitration and Mediation Center for the Americas Mediation and Arbitration Rules).
Such arbitration shall be conducted by a single arbitrator. The sole remedy that can be awarded to the client in the event that an award is granted in arbitration is refund of the entire consulting fee. Without limiting the generality of the foregoing, no award of consequential or other damages may be granted to the client. If the terms of this Agreement are acceptable, please make your appointment. By doing so, the client acknowledges that he/she understands, accepts and agrees to abide by the terms hereof.
I HAVE CAREFULLY READ THIS AGREEMENT or had it read to me in my native language AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR MY INJURY OR DEATH OR DAMAGE TO MY PROPERTY THAT OCCURS WHILE PARTICIPATING IN CONSULTING AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY NEGLIGENT OR INTENTIONAL ACT OR OMISSION. I ALSO ASSERT THAT I AM OVER THE AGE OF 18 AND HAVE SUFFICIENT MENTAL CAPACITY TO ENTER INTO A LEGAL AGREEMENT ON MY OWN BEHALF OR THAT OF OTHERS.
AUTHORIZATION FOR PATIENT EMAILS AND PHONE MESSAGES
I also authorize Rita Panahi/Rita Panahi, L.Ac. to leave private or confidential health information messages on my voice mail, send a text message or email to the information I have provided.