Our goal is to help you reclaim and maintain your health and well-being through safe and effective natural treatments. To provide you the care tailored to your needs, it is important that you, as the client, read through this document, and ask any questions before beginning your treatment plan.
IN CONSIDERATION for access to the services offered and provided by CASA CALM, LLC d/b/a THE GUILD OF MODERN WELLNESS, a Wisconsin limited liability company, (“The Guild”) and use of the facilities of The Guild located at 21415 W. Greenfield Ave., New Berlin, WI, 53146 (the “Facilities”), THE UNDERSIGNED, for himself/herself as an individual and on
behalf of his or her personal representatives, heirs, assigns, and next of kin (“The Client”), hereby acknowledges and agrees to each of the following TERMS of this INFORMED CONSENT:
1. THE CLIENT WARRANTS AND REPRESENTS that:
a. The Client understands that the particular activities which The Client may voluntarily undertake at the Facilities involve, but are not limited to physical exercise and physical wellness treatments, including stretching and breathing exercises; massage treatments of various kinds including thermal and vibroacoustic massage; acupressure; exposure to oxygen and ozone; exposure to various forms of light including but not limited to LED, LED Red, and infrared light, including during Theralight photo-biomodulation treatments; sauna treatments including exposure to temperatures as high as 195 degrees Fahrenheit for extended periods of time; sensory deprivation treatments; bioresonance treatments; pulse electromagnetic treatments, commonly referred to as PEMF treatments; vibrational plate treatments; microneedling treatments, commonly referred to as a SkinPen procedure which may also include a platelet rich plasma treatment, commonly referred to as a PRP treatment, use of exercise and rebounder equipment; and aerobic activity (the “Activities”);
b. The Client is in sufficient physical condition, and physically and mentally able to independently engage in each of the Activities in which The Client chooses to participate (such as undressing for a treatment);
c. The Client understands that The Guild is not a health care facility nor does The Guild provide emergency medical care, and thus, any need by The Client for such a health or medical care facility may not be immediately available in the event of The Client sustaining an injury or health event during the Activities;
d. The Client has specifically reviewed the definition of Pre-Condition in Section 1.e. below, and has reviewed and/or discussed the contraindications and/or precautions for any desired Activities with an employee of The Guild prior to
participation;
e. The Client is not aware of any disability, diagnosis, impairment, treatment, medication or other ailment (“Pre-Condition”) preventing The Client from active or passive exercise, nor does The Client have any knowledge or received a diagnosis of any Pre-Condition which has been indicated to be or potentially be detrimental to The Client’s health, safety, comfort or condition while undertaking any of the Activities;
(i). And with respect to The Client engaging in whole body vibration plate
treatments, any Pre-Condition, including:
• Pregnancy
• Diabetic with complications, such as Neuropathy or Retinal Damage
• Recent surgery
• Pacemaker
• Epilepsy
• Migraines
• Cancer or Tumors
• Herniated disks
• Spondylolisthesis or Spondylolysis
• Joint Replacements
• Metal Pins or Plates
• Any of the above without pre-approval from your medical doctor;
(ii). And with respect to The Client engaging in Theralight photo-biomodulation treatments, any Pre-Condition noted by the Theralight manufacturer, including:
• Pregnancy
• Cancer
• Organ Transplant
• Immune Suppresant Medication
• Steroid Injection or Treatment
• Open Wounds or Skin Lesions
• Photosensitizing Medication
• Seizure Disorder, such as Epilepsy, or Electrical Sensitivity, also known as Electrical Oversensitivity (EO), Electromagnetic Stress, or Electrical Hypersensitivity (EH or EHS)
• Any of the above without pre-approval from your medical doctor;
(iii). And with respect to The Client engaging in a SkinPen microneedling procedure, which may or may not include a PRP treatment, any Pre-Condition noted by the SkinPen manufacturer, including:
• Pregnancy
• Autoimmune Therapy
• HIV or Hepatitis
• Open Wounds or Skin Lesions or Sores (including Herpes Simplex)
• Isotretinoin Use (6 months wait time is recommended)
• Cancer, and specifically Skin Cancer
• Chemotherapy Treatments (within 1 year)
• Acute and Chronic infections, Sepsis
• Skin Diseases (e.g. SLE, Porphyria, Allergies)
• Severe Metabolic and Systemic Disorders
• Abnormal Platelet Function, including Blood Disorders,
Hemodynamic Instability, Hypofibrinogenemia, Critical
Thrombocytopenia
• Chronic Liver Disease
• Anti-Coagulation Therapy
• Oral or Systemic Cortosteroid Use (must be off for 2 weeks prior)
• Sunburn
• Spray Tanning Products or Self-Tanning Lotions
• Any of the above without pre-approval from your medical doctor;
f. Prior to undertaking any of the Activities, The Client has disclosed to The Guild any known Pre-Condition and will disclose any newly discovered Pre-Condition, and other identified concerns and questions about the Activities. The Client is aware that this disclosure requirement remains a continuing obligation during the
entirety of The Client’s engagement with The Guild in any of the Activities or while using the Facilities; and
g. The Client understands that The Guild makes no guarantees, representations or warranties of any kind or nature, express or implied, with respect to the services or Facilities being available, nor the Activities rendered or results derived therefrom.
THE CLIENT HEREBY RELEASES, WAIVES, DISCHARGES AND RELEASES The Guild, and any affiliate thereof, and for each of them, their directors, officers, agents, assigns, and employees, all for the purposes herein referred to as “Releasees,” FROM ALL LIABILITY OWED TO THE CLIENT, (including The Client’s personal representatives, assigns, heirs, and next of kin), FOR ANY AND ALL LOSS OR DAMAGE, AND ANY CLAIM OR DEMAND THEREFOR ON ACCOUNT OF INJURY TO THE CLIENT’S PERSON OR PROPERTY OR RESULTING IN DEATH OF THE CLIENT ARISING OUT OF OR RELATED TO THE CLIENT’S PARTICIPATION IN THE ACTIVITIES (“LIABILITY”) TO THE FULLEST EXTENT PERMITTED BY THE STATE LAWS OF WISCONSIN, EXCEPT THAT THIS WAIVER AND OF LIABILITY MAY NOT APPLY TO ANY INTENTIONAL OR WILLFUL ACTS COMMITTED BY THE RELEASEES. UNDER NO CIRCUMSTANCES SHALL THE GUILD BE LIABLE FOR INDIRECT, CONSEQUENTIAL OR SPECIAL DAMAGES. Notwithstanding any damages that The Client may incur, The Guild’s entire liability under this Informed Consent and The Client’s exclusive remedy shall be limited to the amount actually paid by The Client to The Guild for the Activities and services rendered to The Client.
THE CLIENT HEREBY AGREES TO INDEMNIFY AND HOLD HARMLESS the Releasees FROM ANY LIABILITY which The Client may incur arising out of or related to THE CLIENT’S PARTICIPATION IN THE ACTIVITIES TO THE FULLEST EXTENT PERMITTED BY THE STATE LAWS OF WISCONSIN.
4. THE CLIENT HEREBY ACCEPTS THE RISK AND ASSUMES FULL RESPONSIBILITY FOR ANY AND ALL RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE arising out of or related to THE CLIENT’S PARTICIPATION
IN THE ACTIVITIES TO THE FULLEST EXTENT PERMITTED BY THE STATE LAWS OF WISCONSIN. The Client furthermore acknowledges that The Client has a responsibility: (a) to act within the limits of The Client’s ability; (b) to heed all warnings regarding participation in the Activities, including but not limited to the contraindications listed in Section 1.e. above; (c) to maintain control of The Client’s person and any applicable equipment or devices; (d) to refrain from acting in any manner which may cause or contribute to death or injury for The Client or to other persons; and (e) to review and discuss any potential after effects noted below,
including:
• Redness
• Swelling
• Heat sensitivity
• Pain
• Increased bowel movements and increased urination
• Overeating after treatments
• Failure to maintain appropriate diet and exercise regimen
5. Prior to signing this Informed Consent Form, The Client has had the opportunity to
contact a representative of The Guild to discuss, question and/or negotiate the terms
set forth herein.
Having thoroughly read and understood the TERMS and understanding the rights which I have
voluntarily given up without any undue pressure or inducement being made to me as The
Client, I acknowledge and agree to the TERMS provided in this Informed Consent by my
electronic signature below.