Acknowledgment and Waiver of Liability Form

Acknowledgment and Waiver of Liability I, __________________________, hereby certify and agree as follows: I accept full responsibility for my health and voluntarily complete this Acknowledgment and Waiver of Liability. I certify that I am seeking the consultation and treatment services of Kevin Tate, Britney Tate and Chakra Chack for alternative healing suggestions and therapies, which I fully understand are not medical diagnoses or treatments or substitutes for medical diagnoses or treatments. I certify that with respect to any medical conditions or concerns I may have, I have been advised to consult with my personal care physician, and understand that Kevin Tate, Britney Tate and Chakra Chack is not a primary care physician, and I do not view them as my physician. Their practice specializes in a natural approach to healing including, but not limited to, nutrition and energy. I understand that Mr. and Mrs. Tate do not handle medical conditions or emergencies and do not maintain hospital privileges. I also understand that Kevin and Britney Tate formerly practiced reiki and other alternative medicines but are not trained as a family practitioner nor internist. In seeking to become a client of Kevin Tate, Britney Tate and Chakra Chack; I understand I am seeking analyses and/or therapies that may not be FDA registered or approved and may not be offered by practicing physicians (allopathic or otherwise) and which may be considered experimental. These include, but are not limited to Reiki, Nutrition, Essential Oils and Energy Balancing techniques. I also understand that email is not confidential, secure or 100 percent reliable. If I have an urgent question I will call their contact numbers on file. If I feel it is an emergency I understand that I need to call 911 or go to the nearest emergency room. I understand and agree that neither Kevin Tate, Britney Tate and Chakra Chack make any claims whatsoever, expressed or implied, regarding effects or outcomes of the analyses or therapies provided, and shall not be liable for same. I certify that I seek the advice and treatment of Kevin Tate, Britney Tate and Chakra Chack solely in my personal capacity, and do not represent any governmental agency, law firm, attorney, or investigator. I am not involved in a lawsuit nor am I gathering information for a potential lawsuit. I understand and agree on behalf of myself, my dependents, heirs, administrators, legal representatives, and assigns, to release and hold harmless Kevin Tate, Britney Tate and Chakra Chack and any and all associates, employees, agents and representatives thereof, from any and all liability for illness, injuries, or death, and for any losses or damages relating thereto, however occurring, in relation to my consultation with and/or treatment by Kevin Tate, Britney Tate and Chakra Chack. Without limitation, I understand and agree that neither Kevin Tate, Britney Tate and Chakra Chack, nor any associates, employees, agents or representatives thereof, is liable for any direct, indirect, consequential, or incidental damage, injury, death, loss, delay, or inconvenience of any kind which may be occasioned by reason of any act or omission, including, without limitation, any willful or negligent act or failure to act, or breach of contract. My signature below indicates that I have carefully read and reviewed this Acknowledgment and Waiver of Liability, and I fully understand all of its terms and conditions; I recognize and accept all risks and limitations involved in seeking advice and treatment therapies from Kevin Tate, Britney Tate and Chakra Chack and associates, employees, agents and representatives thereof; I have not relied upon any other promises, agreements or representations by Kevin Tate, Britney Tate and Chakra Chack, or any associates, employees, agents or representatives thereof concerning the treatment provided or the terms of this Acknowledgment and Waiver of Liability; I have been encouraged by Kevin Tate, Britney Tate and Chakra Chack to seek the advice of legal counsel concerning this Acknowledgment and Waiver of Liability; and I execute and deliver this Acknowledgment and Waiver of Liability freely and voluntarily and without duress or coercion and with full knowledge of the representations contained herein and the rights relinquished, surrendered, released and discharged hereunder. UNDERSTOOD, ACCEPTED AND AGREED
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Client Information Form

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