March 2021 General Liability Waiver

General Waiver and
Release of Liability

For all Patients, Clients, Students

I, the undersigned, hereby acknowledge and understand that the wellness services, programs and activities (excluding professional mental health counseling services) (the “Services”) offered by Synergy Wellness Center, LLC (“Synergy”) are not designed or intended to diagnose, treat, mitigate, prevent or cure any physical, psychological, or emotional condition or to serve as a substitute for diagnoses or treatments determined by a licensed medical doctor, mental health counseling provider, or other licensed specialist. I agree I am not seeking the Services for diagnostic or treatment purposes. I certify that with respect to any medical, psychological, or emotional conditions or concerns I may have, I have been advised to consult with my licensed primary care physician and/or a licensed mental health counselor, as applicable. I also understand that it is my responsibility to discuss any and all information provided during Services involving holistic health or nutritional consultations and coaching with my primary health care provider and any other medical or mental health care providers/specialists with whom I have a relationship. If I am under the care of a medical doctor and/or mental health professional, I represent and warrant that I have made members of my care team aware of my intended participation in the Services and they have approved of the same. I certify that all information provided by me to Synergy with respect to my physical, psychological, emotional and nutritional health is complete, truthful and accurate.

I acknowledge and agree that neither Synergy nor any of its employers or contractors conducting the Services on behalf of Synergy have made no warranties, representations or guarantees of any kind, whether expressed or implied, regarding the results that may be achieved, if any, from my participation in any of the Services.

I acknowledge Synergy reserves the right to refuse my participation in the Services or my continued presence at Synergy’s premises in the event I am unable to conduct myself in a mature and respectful manner. I acknowledge that I am prohibited from bringing alcohol or illegal substances onto the Synergy premises. Should a staff member discover I am in possession of alcohol or illegal substances, or a staff member, acting in his/her sole discretion, reasonably infers from my behavior that I am under the influence of the same, I agree to leave the premises immediately when asked, without disruption or challenge, and agree to be held responsible for all charges associated with my scheduled Services. I acknowledge that Synergy shall not be responsible for arranging for my transit to or from Synergy’s premises under any circumstances.

To the extent not limited by applicable law, I, on behalf of myself and my successors, heirs, and assigns, do hereby discharge, waive, release and otherwise hold harmless hereby release and hold harmless Synergy and its managers, members, employees, contractors, representatives, agents and assigns, from and against any and all liabilities, losses (including death, personal injury and illness, including, but not limited to, COVID-19), damages, costs, expenses (including attorneys’ and other fees) and any other claim relating to or arising from my participation in any of the Services, my client relationship with Synergy, my presence at Synergy’s premises, and my own negligent and/or reckless behavior or conduct.


Regarding COVID-19:

High Risk patients are recommended to stay at home at this time; however, there are daily activities that are essential to your health and well-being. We highly recommend high risk patients avoid leaving your home unless necessary. I further acknowledge that I am voluntarily participating in any services or activities at Synergy Wellness Center LLC with the full knowledge and understanding that said activities are taking place during the COVID-19 pandemic. I understand that while Synergy Wellness Center LLC and its employees and contractors will abide by all local, state, and federal government laws and guidelines, as well as CDC guidelines, in an attempt to keep employees and guests safe, that I assume ALL risks associated with participation in said activities during said pandemic, including but not limited to: any illness and any adverse physical and/or psychological effects from the same and/or loss of any income or other monetary loss incurred as a result of the effects of said illness and/or costs incurred in the treatment of the same. I accept full and total responsibility for my own health and agree to release, hold harmless, and indemnify, to the extent permitted by the law, Synergy Wellness Center LLC, its employees and contractors from any liability for any illness, injury, loss or damages I many incur as a result of contracting COVID-19 as a result of engaging in said above referenced activities. By signing this form, I acknowledge that I may contract COVID-19 anywhere including this facility, and I hold all the Synergy Wellness Center healthcare providers and staff harmless for any health-related conditions that may come from Coronavirus COVID-19.


In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows: I hereby certify that I am the parent or guardian of ___________(Enter Minor's Full Name below)___________ and do hereby give my consent without reservation to the foregoing on behalf of this individual.

I acknowledge I have read this document in its entirety and fully understand it is a Waiver and Release of Liability. I represent and warrant I am signing this document freely and willfully and not under fraud or duress. I understand that the agreements and obligations acknowledged by me hereunder are continuing and shall apply to all Services received by me and/or interactions with or at Synergy, whether occurring today or at any point in the future.

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