Liability Waiver and Release
MOVEMENT THERAPY
VITALITY FOREVER, CARLY BELLE, DISCLOSURE AND WAIVER OF LIABILITY AGREEMENT
I, the undersigned (“Client”)______________________________, acknowledge that I have read and understand the contents of this liability agreement.
INITIAL
_________1. Vitality Forever, Carly Belle, is a wellness consultant and physical trainer who does not function as a physician, diagnose, or treat disease, nor does her services replace a licensed physician's necessary services.
_________2. Vitality Forever, Carly Belle, makes no representations, claims, or guarantees regarding the efficacy of her recommendations. The recommendations are based upon a combination of her experience in the fitness and wellness field and education. Vitality Forever, Carly Belle, is not a medical service or health care treatment.
_________3. I understand that the nature of the recommended treatments for my care will be explained to me, and I will have the opportunity to ask questions of those involved in my care. I am not being forced to accept treatment.
_________4. Individualized and Group recommendations are offered and applied as an educational and informative consultation. Any action taken because of the consultation is done at the sole discretion and risk of the Client. Therefore, it is strongly recommended that you maintain a relationship with one or more physicians qualified to care for a health condition(s) in addition to any health consultation.
_________5. The client’s signature verifies that the Client has NOT been told to discontinue treatments with any other medical specialists or health care providers. The client’s signature is given before rendering any service, advice, and/or recommendations.
_________6. The client acknowledges full self-accountability. The client understands that Vitality Forever does not medically discriminate, racially discriminate, gender discriminates or politically discriminate. The client is fully aware that there is no tolerance for discrimination.
__________7. The client takes full RESPONSIBILITY and accountability for their health and safety regarding physical injury and Covid-19, etc. The client agrees to be fully accountable for their health, and Vitality Forever is not to be blamed for any health issues the client acquires or has had as a pre-existing condition. Vitality Forever, Carly Belle, and the YMCA Palm Desert are not held liable for any personal injuries. No physical blame or litigation shall be laid claim to these two entities.
_________8. Financial Policy: (If applicable to Private Sessions) Clients are fully responsible for all professional services received. All accounts will be considered late after 10 days of non-payment. After 10 days, a late monthly fee and service charge of $25 will be added to the account due and will continue to accrue for 3 months. After 2 months of non-payment overdue accounts will be referred to a collection agency. By signing this waiver, you agree to pay your total account balance, including all late fees, and 35% of the balance will be added to the account balance for collection agency fees. Vitality Forever, Carly Belle, is not contracted with insurance companies and does not bill for services.
_________9. I, the undersigned, understand that I am responsible for all charges under our agreement. By signing below, you agree to comply with the above policies and acknowledge that you understand all terms, verbiage (language) and concepts herein. Furthermore, Client agrees not to hold Vitality Forever, Carly Belle, liable for any injuries, costs or damages related to the services provided other than for willful misconduct or gross negligence. I understand this consent agreement and have executed it freely and willingly.
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By signing this waiver, I agree to the above terms and conditions.
NAME (PRINT) ____________________________________________________________
NAME (SIGNATURE) _______________________________________________________
DATE: _______________________________
PHONE: _____________________________
EMAIL: ___________________________________________________________________
EMERGENCY CONTACT: ________________________PHONE:________________________
Carly Belle; ACPT, PWR, CNS, CES, 500AYT
Vitality Forever
(c) 208-720-2242
FACEBOOK. vitalityforever. carly.s.belle
VENMO merchant systems: Carly Belle @Carly-Belle-2