RELEASE AND WAIVER OF LIABILITY AND INDEMNITY
THIS FORM MUST BE SIGNED BY ALL PARTICIPANTS. IF PARTICIPANT IS
UNDER 18 YEARS OF AGE, FORM MUST BE SIGNED BY MINOR AND HIS/HER
PARENT/GUARDIAN.
IN CONSIDERATION of the undersigned Participant being permitted to voluntarily utilize the
Upland Hills Health, Inc. (“Upland Hills”) Wellness Center (the “Center”) facilities, equipment,
programs and services, participant and, if applicable, Participant’s undersigned Parent/Legal
Guardian (individually and collectively referred to as “Participant”) hereby:
1. ACKNOWLEDGES, agrees and represents that Participant understands that the Center
activities involve certain risks. Participant also acknowledges that there are potential
risks of which may presently be unknown. Participant understands that Wellness Guide
Center does not insure participants in Center treatments, that any coverage shall be
through personal insurance at Participant’s expense and that Wellness Guide Center
has no responsibility or liability for injury resulting from Participant’s utilization of the
Centers nutritional suggestions.
2. FULLY RELEASES, WAIVES DISCHARGES AND COVENANTS NOT TO SUE
Wellness Guide Center , its Board, agents, employees or designees from any and all
losses, causes of action, claims, damages or liability that Participant, Participant’s
spouse, child(ren), guests, legally authorized representative, assigns, successors and
representatives may have that relates to, arises out of or is any way connected to
Participant’s use of the Center or Participant’s participation in Center nutritional
suggestions.
3. AGREES TO DEFEND INDEMNIFY AND HOLD HARMLESS Wellness Guide Center,
its Board, agents,
Employees or designees from and against any and all claims of any nature including all costs,
expenses, and fees arising out of or resulting from Participant’s actions during the Center’s
protocols.
4. CONSENTS to receive emergency medical treatment which may be deemed advisable
in the event of accident or illness while participating in the protocols.
By signing below, Participant acknowledges that s/he has had the opportunity to review, discuss
and ask questions about the terms and conditions contained herein.
PARTICIPANT ACKNOWLEDGES THAT S/HE HAS READ THIS RELEASE AND WAIVER
OF LIABILITY,
UNDERSTANDS ITS TERMS, UNDERSTANDS THAT S/HE WILL BE GIVING UP
SUBSTANTIAL RIGHTS AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT
ANY INDUCEMENT OR GUARANTEE BEING MADE.
Wellness Guide Center Informed Consent to Treat
I hereby request and consent to the performance of treatments and other procedure within the scope
of practice of Naturopathic Therapies (or on the patient named below, for whom I am legally
responsible)
I understand that methods of treatment may include, but are not limited to: Organic supplements,
herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared and
the teas consumed according to the instructions provided orally and in writing. The herbs may have an
unpleasant smell or taste. I will immediately notify a member of the center of any unanticipated or
unpleasant effects associated with the consumption of the herbs or treatment.
By voluntarily signing below, I show that I have read, or have had read to me, the above consent to
treatment, have been told about the risks and benefits of Holistic treatment and other procedures, and
have had an opportunity to ask questions. I intend this consent to cover the entire course of treatment
for my present condition and for any future condition(s) for which I seek treatment.