RELEASE AND WAIVER OF LIABILITY
OF
RETO HEALTH AND PERFORMANCE LLC
Below please find the liability waiver for RETO HEALTH AND PERFORMANCE, LLC (hereinafter, “Reto Health”, or the “Company”). By signing below, you, the undersigned, agree to hold Reto Health harmless from all liability associated with the treatments, physical therapy, personal training, exercise regimes, nutritional services and psychological services offered by Reto Health (collectively, the “Treatment”).
I will consult with my provider at Reto Health regarding any medications I am currently taking and any tendencies that may be problematic. I give permission to my provider to perform the chosen procedures and will release and hold the provider their staff, and Reto Health, harmless from any and all liability that may result from this Treatment, including but not limited to disability or personal injury arising from the Treatment or table accommodation. I will give an accurate account regarding medical questions asked by my provider including but not limited to special accommodations as well as all known allergies or prescription drugs or products I am currently ingesting or using topically, and am engaging in the treatment at my own risk.
I understand medication or cosmeceuticals such as prednisone, aspirin, retin A or blood pressure medication, any and all medications used to treat acne, antibiotics that are taken either orally or topically, hormonal changes that naturally occur during your menstrual cycle, any and all products applied topically to the skin, and caffeine, nicotine and alcohol consumption are all items that can affect the Treatment. I understand my provider will take every precaution to minimize or eliminate negative reactions as much as possible, and as such I hereby release the provider and Reto Health from any and all liability or responsibility for any such injury or damage. Reto Health and its owners, affiliates, subsidiaries, employees, agents, and authorized persons do not make any promises, guarantees, or otherwise. regarding the results one may achieve following completion of the Treatment.
Reto Health’s services are not, and should not in any way be considered a substitute for medical advice or assistance. If I believe I may be in need of medical advice or assistance, I should call a certified and qualified medical professional. You, the undersigned, should never avoid or delay seeking professional assistance if you believe you are in need, and you should not rely upon the information given by us as a diagnosis or as medical advice.
Reto Health is not liable or responsible for users who misuse or abuse the information or advice we provide. Furthermore, Reto Health is not liable or responsible for advice, diagnosis, care or treatment given by any medical professional based upon my perception of information Reto Health provide in person or on our website.
The Treatments and services received at Reto Health centers are not intended to be a substitute for professional medical treatment. Reto Health‘s patients have been known for satisfaction of completed Treatments, but results may vary depending on the individual. No guarantee is provided or implied. I will fully indemnify and hold harmless Reto Health, its affiliates, subsidiaries, representatives, agents, staff and suppliers from and against all liabilities, claims, expenses, damages and losses, including legal fees, arising out of or in connection with the Treatments, services and/or facilities.
I will seek the advice of my physician or other qualified health care provider with any questions I may have regarding a medical condition or treatment and before undertaking a new health care regimen, and never disregard professional medical advice or delay seeking it.
Reto Health expressly disclaims all warranties and responsibilities of any kind, whether express or implied, for the accuracy or reliability and for the suitability, results, effectiveness or fitness for any particular purpose of the services, procedures, advice or Treatments referred to herein, such suitability being my sole responsibility and the reliance upon or use of same by me is at my own independent discretion and risk.
I fully understand and acknowledge that (a) the activities in which I will engage as part of the Treatment provided by Reto Health and the equipment I may use as a part of that Treatment have inherent risks, dangers, and hazards and such exists in my use of any equipment and my participation in these activities; (b) my participation in such activities and/or use of strains, fractures, partial and/or total paralysis, death, or other ailments that, could cause serious disability; (c) these risks and dangers may be caused by the negligence of the representatives or employees of Reto Health, the negligence of the participants, the negligence of others, accidents, breaches of contract, or other causes. By my participation in these activities and for use of equipment, I hereby assume all risks and dangers and all responsibility for any losses and/or damages whether caused in whole or in part by the negligence or the conduct of the representatives or employees of Reto Health, or by any other person. I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify Reto Health and their representatives, employees, and assigns from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my use of any equipment or participation in these activities. I specifically understand that I am releasing, discharging, and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the representative or employees of Reto Health.
I hereby acknowledge and understand that this is an important legal document relating to my rights, and by singing this document, I am waiving legal rights I may have against Reto Health for any Treatment services, exercise regime, nutritional plans or advice provided by Reto Health.
I hereby unconditionally release and forever discharge and hold harmless Reto Health and any related persons, entities, their respective directors, officers, employees, agents, contractors, partners, shareholders, successors, assignees, franchisors, franchisees, affiliates or subsidiaries from any and all actions, liabilities, damages, losses, costs, expenses, claims or demands (including without limitation those based on negligence, gross negligence and/or product liability, breach of contract, or breach of any statutory or other duty of care owed under applicable laws) that I, may heirs, next of kin, spouse, guardians, legal representatives, executors, administrators, successors and assigns now have or may hereafter have for any injury to me or my property, resulting directly or indirectly from the Treatment or the provision thereof.
I hereby affirm that I am 18 years of age or older. I have carefully read this document and I understand its contents. I am aware this document is a release of all liability and a contract enforceable against me (and my heirs, next of kin, distributees, guardians, legal representatives, executors, administrators, successors and assigns) in any court of law, including but not limited to any state or federal courts of competent jurisdiction in Miami-Dade County, Florida. I have signed this document of my own free will and without coercion.
Table Accommodations
Reto Health’s standard tables are of the greatest quality and accommodate up to 400 pounds. It is important to inform your provider prior to your service if there is an accommodation of any kind that would need to be made for your personal safety and that of our provider, if so, we will happily make adjustments to fit specific needs. Reto Health shall not be liable or responsible for any personal injury or consequential damage of nature, whatsoever, in direct correlation to our equipment, including our treatment tables. Please note that Reto Health does not ever discriminate on the basis of weight. However, it is important to inform your aesthetician if there are any limitations special needs prior to your service.
I consent to and authorize Reto Health to administer physical therapy Treatment, personal training, nutrition consulting and psychological consulting or other Treatment under the direction and supervision of the physical therapist or other employees of Reto Health. I understand and am informed that, as in the practice of medicine, physical therapy may have some risks. I understand that I have the right to ask about these risks and have any questions about my conditions answered prior to Treatment. I know it is up to me to inform the physical therapist/staff about any health problems or allergies I have, as well as medications I am taking.
CONFIDENTIALITY AGREEMENT and CONSENT TO TREATMENT
CONFIDENTIALITY AGREEMENT
Ordinarily, the information obtained during assessment or treatment is held confidential.
I understand and consent for the sharing of necessary information between the providers at Reto Health and Performance LLC in order to improve and facilitate my treatment.
Additionally, and consistent with relevant mental health laws and professional ethics, confidentiality may be breached under the following circumstances:
1. Client authorized release of information with a signature.
2. The therapist is ordered by a court to release information.
3. For supervision purposes, therapists discuss clients in supervision.
4. A client enters into litigation against one of the doctors.
5. A client is at risk of harming him or herself.
6. A client presents a serious risk of harm to others.
7. Any suspected or renewed child/elderly abuse and/or neglect.
8. In the last three cases, the therapist is required by law to protect life by informing emergency
contact, legal authorities and/or potential victims.
9. Your managed Care Insurance requires the following information: symptoms, severity of
symptoms, level of functioning, diagnosis, treatment plans, and sometimes progress notes to
ensure quality of services and payment.
CONSENT FOR TREATMENT
I understand the above limitations to confidentiality and if I have any questions will discuss them with my therapist.
I understand that I have voluntarily agreed to and give consent for treatment (psychotherapy,
psychological testing if appropriate).
I understand the importance of coming to my appointments and agree to attend all scheduled sessions during the treatment period.
I understand the importance of and agree to arrive at all scheduled appointments on time in order to receive the full amount of time scheduled.
I agree to provide 24 hours notice of cancellation of an appointment or I will be charged for the full fee of the time scheduled.
Tele-Mental Health Informed Consent
I hereby consent to participate in tele-health with, Dr. Cristina Grand from Reto Health and Performance LLC, as part of my psychological treatment. I understand that tele-mental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations (with video included). I understand the following with respect to tele-mental health:
1) I understand that I have the right to withdraw consent at any time without affecting
my right to future care, services, or program benefits to which I would otherwise be
entitled.
2) I understand that there are risks, benefits, and consequences associated with tele-
mental health, including but not limited to, disruption of transmission by technology
failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or
limited ability to respond to emergencies.
3) I understand that there will be no recording of any of the online sessions by either
party. All information disclosed within sessions and written records pertaining to those
sessions are confidential (as indicated in confidentiality form).
4) I understand that the privacy laws that protect the confidentiality of my protected
health information (PHI) also applies to tele-mental health unless an exception to
confidentiality applies (as indicated in confidentiality form).
5) I understand that during a tele-mental health session, we could encounter technical
difficulties resulting in service interruptions. If this occurs, end and restart the session. If
we are unable to reconnect within ten minutes, please call me or text me at 305-596-
4663, you can also call 305-323-2293. The session may need to be re-schedule.
6) I understand that if I am having suicidal or homicidal thoughts, actively experiencing
psychotic symptoms or experiencing a mental health crisis that cannot be resolved
remotely, it may be determined that tele-mental health services are not appropriate, and that a
higher level of care may be required.
7) I understand that my therapist may need to contact my emergency contact and/or
appropriate authorities in case of an emergency.
Emergency Protocols: You agree to inform me of the address at the beginning of each session if different from your home or office address. Your emergency contact person will be notified if needed and only if an emergency has taken place. I have read the information provided above and discussed it with my therapist. I understand the information contained in this form and all of my questions have been answered to my satisfaction.
PAR-Q
If I were asked these questions, my answers would be the following.
Has your doctor ever told you that you have a heart problem and therefore should only do physical activity recommended by him? – NO
When you do physical activity do you feel chest pain? – NO
In the last month and while at rest, have you felt chest pain? – NO
Do you lose your balance due to dizziness or vertigo, or have you ever lost consciousness? – NO
Do you have a bone or joint problem that could be made worse by an increase in your usual physical activity? – NO
Is your doctor currently prescribing medications (for example, diuretics) for your blood pressure or heart? – NO
Do you know of any other reason why you shouldn’t be physically active? – NO
Informed Consent
The possible benefits and risks to which you are exposed during a physical activity program are explained below:
Benefits:
• Reduction of diastolic or systolic blood pressure at rest.
• Improved maximal oxygen consumption.
• Increased capillary density in skeletal muscle.
• Increase lung capacity.
• Delayed threshold for onset of signs or symptoms of disease
• Lower insulin needs, lower insulin resistance.
• Higher presence of high-density lipoprotein cholesterol (HDL), lower presence of triglycerides.
• Lower body fat and less abdominal fat.
• Greater muscle strength and/or power, the result of neuromuscular, morphological and hormonal coordination adaptations.
• Greater resistance to efforts involving neuromuscular involvement in the presence of fatigue.
• Improvement of cognitive functions.
• Reduced states of anxiety and depression.
• Elimination of mental and nervous tension. Provides a feeling of well-being.
• Improves mood.
Risks:
• Increased pain in the joints or inflammation in the tendons due to overload.
• Late myalgia (soreness).
• Hypoglycemia.
• Amenorrhea.
• Muscle or bone injuries.
• Exceptionally: myocardial infarction, sudden death, syncope, hyperthermia, dehydration.
Manifests:
- That on the occasion of my request to participate, I have been sufficiently informed and in an understandable language about the characteristics of the sports activity in which I am going to participate and about the physical conditions required for said participation.
- That I have been sufficiently and clearly informed about the risks and about the security measures to be adopted in carrying out the same.
- That I have carried out the mandatory medical examination of aptitude to carry out such physical/sports activity and that I have no medical contraindication.
- That I know and understand the regulations governing sports activities and that I fully agree with them, submitting myself to the power of direction of the coach.
- That I voluntarily assume the risks of the activity and, consequently, exempt the coach from any damage or harm that he may suffer in the development of the activity. Such exemption does not include damages resulting from the fault or negligence of the coach.
I HAVE READ THE ABOVE WAIVER AND RELEASE, CONFIDENTIALITY AGREEMENT, CONSENT TO TREATMENT, TELE-MENTAL HEALTH INFORMED CONSENT, PAR-Q AND INFORMED CONSENT AND, BY SIGNING THE “RETO” DOCUMENT, I AGREE TO ITS CONTENTS. IT IS MY INTENTION TO EXEMPT AND RELIEVE RETO HEALTH AND PERFORMANCE LLC FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE, OR WRONGFUL DEATH BY ANY CAUSE