Vie Universoul Wellness

Harmonic Egg – Informed Consent Form

I, Carly Takeda hereby voluntarily consent to a relaxation therapy session at Vie Universoul Wellness. I have read the program protocol and conditions and agree to adhere to with all recommendations, to the best of my ability, in order to receive maximum benefit.

I am responsible for the decision to seek this type of relaxation therapy program that could include improvement of the physical, psychological / emotional and environmental aspects of my illness. I recognize that the Vie Universoul Wellness staff do not treat any specific disease or illness and they are not licensed, certified, or registered by the province as a health care professional. However, all staff members are trained technicians and possess the proper training to administer sessions for clients. I recognize the possibility that this program may not prove successful or accomplish the results I expect or hope for. I understand that best results are obtained following a protocol of multiple sessions, followed by regular maintenance sessions.

I am fully informed that this approach to health differs from, and may not be recognized by, conventional medical standards. Clients should discuss any recommendations made by Vie Universoul Wellness with their medical professional. As further inducement to Vie Universoul Wellness to provide services for me, I hereby waive any claims or demands that I might now or hereafter have against Vie Universoul Wellness or its owners or staff that may arise, or are deemed to arise from participating in therapy programs at Vie Universoul Wellness, and I hereby further release Vie Universoul Wellness and its owners and consultants from any and all liability of any nature arising out of or in any way relating to the therapy sessions I will receive at Vie Universoul Wellness. Vie Universoul Wellness does carry liability insurance as deemed necessary by the Province of Alberta and the leasing agent in which we are doing business on their property.

I understand that Vie Universoul Wellness reserves the right to deny treatment if it is not deemed by Vie Universoul Wellness to be in the best interest of the client(s) or staff.

It is understood that any therapy sessions, remedies, nutritional supplements, or treatment modalities are intended to improve overall body performance and are not intended or implied to treat or cure any specific medical condition or illness. It is understood that any suggestions regarding remedies and nutritional supplements are only Vie Universoul Wellness‘s best recommendation and are at no time to be considered a prescription.

Those under 18 years of age must have this form signed by a parent or guardian.

Date: 01/10/2022

Emergency Contact:

Stephanie Takeda
4033082822

Please sign using a stylus, your mouse, or your finger below to authorize this contract. By electronically signing this document, you agree to the terms established above. After the document is signed, you can proceed to print it.



Client Information
Signed on Tue Feb 15 2022 23:16:02 GMT-0700 (Mountain Standard Time)
IP Address: 174.0.8.127

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