Client's Representations and Warranties
For all Patients, Clients, Students
I hereby voluntarily agree to participate in individual and/or group services (the “Services”) offered and administered by Synergy Wellness Center, LLC and its authorized agents, employees and contractors (individually and collectively, “Synergy”). I acknowledge that the term “Services” does not include professional mental health counseling services offered by Synergy and that I will be required to fill out different forms with respect to my participation in such professional services.
I hereby declare myself physically and mentally sound and suffering from no condition, injury, impairment, disease, infirmity, or other illness that would prevent my participation in the Services. I acknowledge I have obtained my physician’s approval prior to my participation in the Services, and that I will obtain further physician’s approval(s) with respect to the continuation my participation in the Services if, at any time, I suffer any adverse change in my physical or mental condition. I further acknowledge that I have either had a physical examination and have been granted permission by my physician to participate in the Services, or I have elected to participate in the Services without my physician’s approval. I further acknowledge that it is my responsibility to keep abreast of any changes or deterioration in my physical, mental or emotional condition.
I acknowledge and understand that the instructors and other personnel of Synergy are not trained medical professionals and that any information provided to me by Synergy neither constitutes nor serves as a substitute for medical advice. I further acknowledge that I, in my sole discretion, may disclose to Synergy the existence of a condition, injury, impairment, disease, infirmity, or other illness that may prevent, hamper, or otherwise affect my participation in the Services, but that Synergy is not qualified to determine if and how my participation in the Services will affect any such condition, injury, impairment, disease, infirmity or other illness, whether positively or negatively. In the event Synergy suggests a modification to an activity to accommodate any such condition, it is my responsibility to evaluate whether or not such modification would aggravate or worsen such condition.
Although Synergy shall exercise reasonable precautions to ensure my safety, I acknowledge and agree that I will be engaging in activities that may pose inherent risks, including but not limited to, bodily injury and death. Additionally, there may be other risks not known or not reasonably foreseeable at this time.
I acknowledge and agree no warranties, representations, or guarantees of any kind, expressed or implied, have been made to me regarding the results I will achieve from participating in the Services. I understand that Synergy will prescribe the most effective methods within the scope of its knowledge to help me achieve my wellness goals, but actual results may vary based on factors beyond the control of Synergy, including, but not limited to, my frequency of participation in the Services, the number and type of physical and mental wellness activities undertaken by me outside of Synergy, and my personal lifestyle and habits. I further acknowledge that the activities undertaken by me during my participation in the Services may be unsuitable, or even dangerous, for another individual to undertake. I therefore agree that I will not share any information provided by Synergy, whether verbal, written or physically demonstrated, with any other person.
I represent and warrant that all of the representations made by me herein are truthful and accurate. I have had the opportunity to ask questions regarding the representations set forth in this document, and if I have asked any such questions, Synergy has answered the same to my satisfaction.