Crystalline Wellness Service Liability Waiver

Please take a few minutes to review and complete the below online Crystalline Wellness Service Liability Waiver, which will be automatically emailed to Crystalline Wellness. Please Note: If you are on a mobile device or experience difficulty with the online form, please download the PDF waiver, manually complete it, and email it directly to crystallinewellnessyoga@gmail.com.

Click for Service Liability Waiver PDF

Liability Waiver

First Name

Last Name

Phone

DOB

Preferred Pronouns

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Name of Emergency Contact

Phone of Emergency Contact

I want to be added to the Crystalline Wellness mailing list.

Do you have any physical limitations that could be aggravated by excerise? (i.e. pregnancy, high blood pressure, back, neck, shoulder or knee problems, etc.) If so, please explain:

Do you have any conditions that could be negatively impacted by intense vibrations and/or sound healing? (i.e. heart conditions/pacemakers, severe hearing impairments, recent head injuries, extreme sensitivities to sound, metal plates or implants, pregnancy in the first or third trimesters, mental health conditions, etc.) If so, please explain:

Do you have any conditions that could be negatively impacted by extreme heat conditions?(i.e. pregnancy, cardiovascular conditions, bleeding disorders, heat sensitivities or lack of sweat, fever or active infections, etc.) If so, please explain:

Essential Oils to Avoid

How did you hear about my services?

Anything else you would like me to know?

The Fine Print

No matter which service(s) you are opting for, it is important that you understand any and all risks. While these sessions offer an opportunity to bring plenty of positive changes into your life, it is still your responsibility to ensure you are doing it in a safe and effective manner. Please be as honest as you can with any physical, emotional or mental limitations you may have upfront, and assume responsibility for providing any updates to your health and well-being as they arise.

You understand that Karen Paisley and/or Crystalline Wellness is not a licensed health professional and will not diagnose, prescribe substances, perform medical treatment, or interfere with the treatment of a qualified physician or other licensed medical professionals. The services offered are considered complementary to traditional Western medical practices. Some of these services are not recommended and are not safe under certain medical conditions. By submitting this waiver, you affirm that a licensed physician has verified your good health, emotional well-being, and physical condition to participate in such programs. In addition, you again agree to make the service provider aware of any medical and/or emotional conditions or physical limitations before each session that you participate in, as you are solely responsible for informing them of any changes that may differ from what you are submitting today.

As is the case with many activities, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If you do experience any pain or discomfort during a session, you will listen to your body, discontinue the activity/session and ask the provider for support. You will continue to breathe smoothly and pay attention to your heart rate and other physical and/or emotional cues you may experience and determine the best course of action for yourself. You assume full responsibility for any and all damages which may incur through the participation of any Crystalline Wellness activities, either virtually or in-person.

If you are pregnant, trying to become pregnant or are post-natal or post-surgical, your submission verifies that you have your physician's approval to participate. You also affirm that you alone are responsible to decide whether a service is appropriate for you and participation is at your own risk.

You have read and fully understand and agree to the above terms of this Service Liability Waiver Agreement. You hereby agree to irrevocably release and waive any claims that you have now or may have hereafter against Karen Paisley and/or Crystalline Wellness as well as the physical or virtual locations where Karen Paisley offers her services. You are submitting this agreement voluntarily and recognize that your submission serves as your signature and complete and unconditional release of all liability to the greatest extent allowed by law in the State of Pennsylvania.

Thank you for submitting the Crystalline Wellness Service Liability Waiver!