Infrared Sauna Waiver / Disclaimer

INFRARED SAUNA INTAKE FORM

Name- ______Phone (h)- (_____)______Address- ______(cell)- _(_____)______Postal Code______(work)- (_____)______Email - ______How did you hear about us?______DOB (mm/dd/yy) - ______

Emergency Contact- ______Phone # -(____)______Indicate your main health concerns in order of importance to you: 1.- ______Since when: ______2.- ______Since when:______3.- ______Since when: ______4.- ______Since when: ______List any Medication and/ or Supplements that you are taking: Medication Supplements 1.- ______1.-______2.-______2.-______3.-______3.-______4.-______4.-______Water Consumption: How easily do you sweat? How much per day? ______Very Easily Average Rarely Please note the following list is considered contraindication for the use of Far Infrared Saunas. Please indicate if any of the following apply to you: 1.- Do you have uncontrolled high blood pressure? Yes No 2.- Do you suffer from Congestive Heart Failure? Yes No 3.- Are you presently intoxicated with increased consumption of alcohol? Yes No 4.- Do you suffer from Parkinson’s, Multiple Sclerosis? Yes No 5.- Do you suffer from a Central Nervous System Tumour or Diabetic Neuropathy? Yes No 6.- Are you pregnant? Yes No 7.- Do you have a fever? Yes No 8.- Have you had a recent joint injury (past 48 hours) that is still hot and swollen? Yes No 9.- Do you have a Pacemaker or defibrillator? Yes No

IF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS- PLEASE CONSULT WITH YOUR DOCTOR BEFORE USING INFRARED SAUNA. Please indicate if any of the following apply to you: 1.- Are you currently taking diuretics, barbiturates, beta-blockers or anti-histamines? Yes No 2.- Are you under the age of 16 or over the age of 65? Yes No 3.- Are you currently having a heavy menstrual period? Yes No 4.- Do you have a metal pin, rod, artificial joint or any other surgical implants? Yes No 5.- Do you have a hard time breaking a sweat? Yes No

IF YOU ANSWERED YES TO ANY OF THE ABOVE, YOU NEED TO BE CAUTIOUS DURING YOUR SESSION. PLEASE SLIGHTLY OPEN THE DOOR OF THE SAUNA TO ALLOW COOL AIR TO COME IN IF YOU ARE TOO HOT. WE WILL SET YOUR FIRST SESSION AT A LOWER TEMPERATURE.

*Your Hosts/Hostesses & Massage Therapists gladly appreciate and accept gratuity for services provided. DISCLAIMER / WAIVER

I, the undersigned, consent to the Infrared Sauna Treatment. I understand that these procedures are for the purpose of detoxification and are not intended to take place of medical care or medications. I clearly confirm that I do not have any contraindications to the Infrared Sauna Treatments. I understand that I can discontinue my treatments anytime. I understand that I take full responsibility for my own health and well-being. I agree to pay my account in full after every treatment. I agree to disclose to City Sweats if my medical health history should happen to change during the time period of receiving Far-Infrared Sauna Treatments. I have read the above disclaimer (including cautions and contraindications for the use of Far- Infrared Sauna) and I agree that I am not currently suffering with any of the above-mentioned contraindications. I have read the recommendation sheet, I have been informed about the fees, I have had the opportunity to ask any questions about its content, and by signing below I agree to disclaim City Sweats its members from any liability in connection with the use of the sauna.

Client Name- ______(please print)

Signature ______Date- ______1928 43rd AVE E Seattle, WA 98112 206.402.5417 HIPAA Consent Form

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize City Sweats Seattle to use and disclose my protected health information to carry out: • Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment). • The day-to-day healthcare operations of City Sweats Seattle I have also been informed of, and given the right to review and secure a copy of the City Sweats Seattle Privacy Policy, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. In understand that City Sweats Seattle reserves the right to change the terms of this notice from time to time and that I may contact City Sweats Seattle at anytime to obtain the current copy of this notice. I understand d that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment and healthcare operations, but that City Sweats Seattle is not required to agree to these requested restriction. However, if City Sweats Seattle does agree then City Sweats Seattle is bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time; however, any use or disclosure that occurred prior to the date I revoke is not affected. I further understand that I have the right to not sign this acknowledgment in order to receive treatment at New Beginnings Wellness Center and Spa. Authorization to communicate Protected Health Information – Check all that apply: ___City Sweats Seattle may leave a detailed message on voicemail at my home #: (_____) ______City Sweats Seattle may leave a detailed message on voicemail on my cell #: (_____) ______City Sweats Seattle may speak with another person (spouse, family member) about my medical condition ___ including /___ excluding information related to mental health, sexually transmitted disease, HIV status and reproductive medicine: Name/Relation: ______Phone #: (____) ______With my signature below, I acknowledge and understand that this information will be kept in my medical record and the instructions above will be honored until revoked by me in writing. It is my responsibility to notify City Sweats Seattle should I change one or more of the telephone numbers listed above. ______Signature Date ______Representative Name

For administrative use only: ______Patient Name Date of Birth ______Relationship to Patient We are unable to obtain the patient’s written acknowledgement of our Notice of Privacy Practices due to the following reasons: ___Patient declined to sign ___emergency situation ___Communication barriers ___Other: :