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”).
Recitals
Tester voluntarily agrees to participate in the testing of PNOE equipment at Tester’s own site and strictly in accordance with instructions provided by the Clinic.
Tester confirms that participation is voluntary and based on full consideration of all information provided, including medical and physical condition disclosures.
Assumption of Risk
Tester voluntarily assumes all risks, injuries, damages, or losses arising from participation, including but not limited to equipment failure, negligence, exposure to COVID-19 or similar viruses, physical injury, or property damage.
Medical Acknowledgment
Tester certifies they are medically fit, have consulted healthcare professionals if necessary, and have no known conditions that would prohibit participation.
Release & Indemnification
Tester waives, releases, and forever discharges Aspen Integrative Medicine and all related entities from any liability arising out of participation, including negligence.
Tester agrees to indemnify and hold harmless Aspen Integrative Medicine Entities from all claims, damages, legal fees, or expenses.
Privacy Policy & Additional Legal Notice
All personal and medical information collected during participation shall be handled in accordance with applicable privacy laws and the Clinic’s Privacy Policy.
Information is used solely for clinical, testing, and operational purposes and is not shared with third parties except where legally required.
This Waiver constitutes the entire agreement between the parties and supersedes any prior discussions or representations.
I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS WAIVER AND SIGN IT VOLUNTARILY.
PARENT / GUARDIAN WAIVER FOR MINORS
The undersigned parent or legal guardian consents to the minor’s participation and agrees to all terms of this Waiver, including indemnification obligations.
