PNOE Consent

ACCIDENT WAIVER AND RELEASE OF LIABILITY FORM

This Accident Waiver and Release of Liability form (the “Waiver”) is made and entered into as of THE SIGNED DATE BELOW (the “Effective Date”) by and between ASPEN INTEGRATIVE MEDICINE (“the “Clinic”) , and THE PATIENT’S NAME ABOVE, (the “Tester”).

WHEREAS, Tester wishes to voluntarily participate in the Activity (defined as “the testing of PNOE equipment by Tester at Tester’s own site, and in strict accordance with any and all instructions provided to Tester by the Clinic).

WHEREAS, Tester has made the decision to participate in the Activity after thoroughly reviewing and considering all of the information provided to it by the Clinic outlining, detailing, and describing the Activity (“Information”).

WHEREAS, Tester affirms that its decision to participate in the Activity is voluntary, and that in making this decision it has considered all relevant information related to its own medical and physical condition.

NOW, THEREFORE, Tester does hereby swear and affirm the following on his/her own behalf and on behalf of his/her executors, administrators, heirs, next of kin, successors, and assigns:

  1. I HEREBY VOLUNTARILY ASSUME ALL OF THE RISKS, HARM, AND DAMAGES THAT MAY OCCUR AS A RESULT OF MY VOLUNTARY PARTICIPATION IN THE ACTIVITY, including by way of example and not limitation: (i) any risks that may arise from negligence or carelessness on the part of the Clinic relating to dangerous or defective equipment or property owned, maintained, controlled or provided by the Clinic; (ii) any risks arising from contracting COVID-19 or other similar virus or from being exposed to COVID-19 or other similar virus; (iii) any risks or damage to my physical health such as, but not limited to: heart problems or heart damage of any kind, any form of muscular or skeletal injuries, and any type of damage to my cardiovascular system; and (iv) any damages that may occur to my personal property.
  2. I am physically fit, have sufficiently prepared or trained for participation in the Activity, and have not been advised by a qualified medical professional to not participate in the Activity. I have made all necessary, appropriate, and reasonable medical inquiries in order to voluntarily declare myself fit for the Activity and I willingly assume the risks of this inquiry. To my knowledge, I do not have a pre-existing condition or any other known or suspected physical or medical symptom or condition that might dispose or incline me towards any kind of damage or harm as a result of participating in the Activity.
  3. There are no health-related reasons, issues, or problems which preclude or should preclude my participation in the Activity.
  4. I have fully read and understood the Information and have no objections and/or reservations with the content of it.
  5. The personal benefit I will derive from participating in the Activity is ample consideration for my consent to voluntarily sign this Waiver and agree to all the terms and conditions herein.
  6. I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns to do as follows:

(A) WAIVE, RELEASE, AND FOREVER DISCHARGE The Clinic and its affiliates, subsidiaries, owners, officials, board members, managers, employees, directors, and staff (collectively “Aspen Integrative Medicine  Entities”) from any and all liability, including but not limited to: any manner of harm, liability, or damage arising from the negligence or fault of Aspen Integrative Medicine Entities for my death, disability, personal injury, harm, property damage, property theft, or actions of any kind which may hereafter occur to me or my property as a result of my participation in the Activity; and

(B) INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE OR PARTICIPATE IN A LAWSUIT AGAINST Aspen Integrative Medicine Entities for any and all liabilities, damages, fines, expenses, legal costs, legal fees, or claims made or arising as a result of my participation in the Activity, whether caused by Aspen Integrative Medicine Entities’ negligence or otherwise, and regardless of the theory giving rise to liability.

Tester acknowledges that Aspen Integrative Medicine Entities are NOT responsible for the errors, omissions, acts, or failures to act of any party, person, or entity conducting any activity on the behalf of the Aspen Integrative Medicine Entities.

This Accident Waiver and Release of Liability Form shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. If any provision of this Accident Waiver and Release of Liability Form is determined to be unlawful, void, or for any reason unenforceable, then that provision shall be deemed severable from this Accident Waiver and Release of Liability Form and shall not affect the validity and enforceability of any remaining provisions.

For the avoidance of any doubt, both Parties certify that they were not asked to sign this Accident Waiver and Release of Liability Form in bad faith.

I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A WAIVER AND RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL.

PARENT / GUARDIAN WAIVER FOR MINORS (under 18 years old)

The undersigned parent or natural guardian does hereby represent that he/she is, in fact, acting in such capacity, has consented to his/her child or ward’s participation in the Activity and has agreed individually and on behalf of the child or ward, to the terms and conditions of the present Accident Waiver and Release of Liability set forth above. The undersigned parent or guardian further agrees to save and hold harmless and indemnify each and all of the Aspen Integrative Medicine Entities’ referred to above from any and all liability, loss, cost, claim, or damage whatsoever which may be imposed upon Aspen Integrative Medicine Entities’ because of any defect in or lack of such capacity to so act and release said Aspen Integrative Medicine Entities’ on behalf of the minor and the parents or legal guardian.