New Patient Paperwork

Please read the following and sign where indicated

I acknowledge that I have chosen to receive stretching services from an employee with Therekos Wellness LLC (which herein shall include all its owners, members, managers, officers, principals, independent contractors, and employees). I recognize and understand that, while unlikely, my participation may result in physical harm, including without limitations muscular damage, skeletal damage, or nerve damage. I willingly assume full responsibility for all risks that I am exposing myself to as a result of my being stretched by Therekos Wellness LLC. By assuming these risks, I understand that I am waiving claims I may otherwise have had.

Health Risk: I hereby warrant that I know of no medical problems that would put me at an increased risk of injury because of receiving a stretch session. I further warrant that I have not made Therekos Wellness LLC aware of any reason why I am unfit to receive their offered services. Reasons why I may be unfit to receive a stretch include, but are not limited to muscular damage, skeletal damage, or nerve damage.

Release: In full consideration of the above mentioned risks and hazards and in full consideration of the fact that I am willingly and voluntarily accepting the services offered by Therekos Wellness LLC and with my full understanding of all of the above, I voluntarily waive, release, discharge, and hold harmless Therekos Wellness LLC of any and all liability, claims, demands, actions, causes of action, rights of services offered by Therekos Wellness LLC, including those allegedly attributed to the negligent acts or omissions of the above mentioned parties. In signing this document, I fully recognize Therekos Wellness LLC, even if they negligently or by some other act or omission cause the injury or damage. This shall remain in effect for future visits unless and until revoked.

I have read this document in its entirety. I fully understand the foregoing assumption of risk and release of liability, and all terms and conditions contained herein, and I understand that by signing below I have released all claims against officers, principals, independent contractors, and employees. I understand that by voluntarily signing this form I am executors, assigns and transferees. If any portion of this agreement is held invalid, I agree that the remainders of the agreements shall remain in full legal force and effect.

I understand that the assisted-stretch/bodywork I receive is provided for the basic relief of muscular tension, and should NOT be substituted for medical examination, diagnosis, Physical Therapy, or treatment of serious ailment. Because assisted-stretching should not be performed on individuals with certain medical conditions, I have stated all known medical history honestly and to the best of my ability.

I also understand that ANY illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will still be responsible for payment of the scheduled appointment.