IN CONSIDERATION of access to and use of the facilities located at Casa Calm (the “Facilities”) of Casa Calm, LLC. A Wisconsin limited liability company (“Casa Calm”), EACH OF THE UNDERSIGNED, for himself/herself, his or her personal representatives, heirs, and next of kin:
- HEREBY WARRANTS AND REPRESENTS that: (i) he or she understands that the particular activities which he or she may undertake involve physical exercise and physical wellness treatments, including by way of example yoga, stretching and breathing exercises, massage treatments of various kinds including thermal massage, acupuncture, exposure to oxygen and ozone, sauna treatments including exposure to temperatures as high as 195 degrees Fahrenheit for extended periods of time, sensory deprivation treatments, bio-resonance treatments, use of exercise equipment, and aerobic activity (the “Activities”); (ii) he or she understands that the Activities may or may not be supervised by Casa Calm employees; (iii) he or she understands that Casa Calm is not a health care facility and emergency care may not be immediately available in the event of an injury or health event during the Activities; and (iv) he or she is in sufficient physical condition and is physically able to undertake all the Activities and to use the Facilities; has no disability, impairment or ailment preventing him or her from active or passive exercise, or that will be detrimental to his or her health, safety, comfort or condition if he or she does so engage or participate.
- HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the Casa Calm or any subdivision thereof, and each of them, their directors, officers, agents and employees, all for the purposes herein referred to as “Releasees,” FROM ALL LIABILITY, TO THE UNDERSIGNED, his or her personal representatives, assigns, heirs, and next of kin FOR ANY AND ALL LOSS OR DAMAGE, AND ANY CLAIM OR DEMANDS THEREFOR ON ACCOUNT OF INJURY TO THE PERSON OR PROPERTY OR RESULTING IN DEATH OF THE UNDERSIGNED ARISING OUT OF OR RELATED TO THE ACTIVITIES OCCURRING WHILE AT THE FACILITIES, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE (BUT NOT INCLUDING INTENTIONAL OR RECKLESS ACTS OF THE RELEASEES).
- HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the Releasees and each of them FROM ANY LOSS, LIABILITY, DAMAGE, OR COST he or she may incur arising out of or related to THE ACTIVITIES WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE (BUT NOT INCLUDING INTENTIONAL OR RECKLESS ACTS OF THE RELEASEES).
- HEREBY ACCEPTS THE RISK AND ASSUMES FULL RESPONSIBILITY FOR ANY RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE arising out of or related to THE ACTIVITIES whether caused by the NEGLIGENCE OF RELEASEES or otherwise (BUT NOT INCLUDING INTENTIONAL OR RECKLESS ACTS OF THE RELEASEES), and furthermore acknowledges, , that he or she has a responsibility to act within the limits of his or her ability, to heed all warnings regarding participation in the Activities, to maintain control of his or her person and any applicable equipment or devices, and to refrain from acting in any manner that may cause or contribute to death or injury for himself or herself or to other persons.
- HEREBY acknowledges that prior to signing this Release and Waiver of Liability, Assumption of Risk and Indemnity Agreement, he or she had the opportunity to contact a representative of Casa Calm to discuss and/or bargain regarding any of the terms set forth herein.
I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW. Due to the fact that the massage therapist must be aware of any existing physical conditions of clients treated, I have stated any/all of my known medical conditions and if necessary give permission to the therapist to consult with my physician. I assume all risks and perils to my person physically, physiologically or psychologically which may ensue during this or subsequent treatments. As well as any effects deemed detrimental which may ensue afterwards as a result of this or subsequent treatments.
Pertaining to treatment utilizing LED light therapy including a Whole Body Vibration Plate Machine:
I understand that the following conditions may present contraindications and preclude me from receiving LED Light Therapy Treatments. I confirm that I DO NOT have any of the following conditions.
- Epilepsy and seizure prone (stay out of room and away while machine is on)
- Skin Cancer (melanoma)
- Pregnancy (do not use the light bed if pregnant or plan to be in the next 8 weeks)
- Heart Trouble (pacemaker – consult with doctor)
- Brain injury (hemorrhage – consult with doctor and request scan)
- Metal plates or pins
I have read and agree to the following:
- I understand the potential risks and side effects of this therapy including but not limited to redness, swelling, heat sensitivity, pain, increased bowel movements and increased urination.
- I understand that each body is different and may require more or less treatments depending on the client’s diet, exercise, metabolism and body type. I understand the treatment is most successful if I also maintain a healthy diet and commit to an exercise program.
- I understand that if after the treatment program, I overeat, the results of this treatment may be reversed.
- I understand that no guarantee has been given as to the results that may be obtained by this treatment. I have read this informed consent and certify that I understand its contents in full. I have had enough time to consider the information and feel I am sufficiently advised to consent to this procedure. I hereby give my consent to have this procedure. If at any time during the procedure I experience pain or discomfort of any kind, I agree to inform the staff immediately and/ or terminate the session at my discretion.
- I am aware that clinical results may vary depending on individual factors, medical history, patient compliance with pre/post treatment instructions, and individual response to treatment. If I do not make an effort to address my diet and exercise, the results achieved may not be retained.
- I have reviewed this consent form. My consent and authorization for this procedure are strictly voluntary. By signing the informed consent form I grant authority to perform the described treatment. The purpose of this procedure, risks, complications, alternative methods of treatment have been fully explained to my satisfaction. Normal activities may be resumed following the treatment. Any photos taken will be used to show the clients progress and may be used in marketing ads.
- Whole Body Vibration Plate Machines are scientifically calibrated exercise machines designed to force your muscles to stretch and contract rapidly in small increments, replicating the same action which occurs during traditional exercising. Vibration exercises use your body weight and gravity to its fullest potential. Please do not use a whole body vibration plate or any other exercise device without getting approval from your doctor.
- Whole body vibrations is not recommended if you are: pregnant, diabetic with complications such as neuropathy or retinal damage, have a pacemaker, recently underwent surgery, suffer from Epilepsy or Migraines, have herniated disks, spondylolisthesis, spondylolysis , have cancer or tumors, have recent joint replacements, have metal pins or plates, or have any other concerns about your physical health. These contra-indications do not mean that you are not able to use a vibration or other exercise device, but it is recommended that you consult your physician first.