INFORMED CONSENT, WAIVER, AND RELEASE
The following statements refer to the professional practice of Beth A. Pfeffer, Angelic Soup, LLC., its owners, partners, successors, lessors, employees, and assigns; hereinafter referred to, individually or collectively, as Practitioner.
By this instrument, I hereby give permission to Practitioner to treat specific conditions or ailments that are detailed on this Intake Form using Frequency Specific Microcurrent ("FSM") treatments.
By providing my electronic signature below, I hereby accept, understand, and confirm that Practitioner does not diagnose illness, disease, or mental disorders, nor prescribe medical treatment or pharmaceuticals. I also affirm that it has been made clear to me that the practice of FSM Treatments is not a substitute for medical examination, diagnosis, or treatment, and that it has been recommended to me that I consult with a medical practitioner such as an M.D. or N.D. for any physical or mental ailment that I may be currently experiencing or may experience in the future.
I acknowledge that FSM is an energetic technological treatment that does not use drugs or any physical manipulation of the body. Consequently, there may be certain conditions or ailments for which FSM is contraindicated. While there are studies showing benefits with FSM treatments, FSM is not routinely used in conventional medical care.
I agree and affirm that Practitioner cannot be held liable for any problem, real or imagined, that might arise as a result of participating in FSM Treatments or Energy Healing sessions. I also affirm that I have provided a true and complete representation of my physical, emotional, and mental health by way of disclosure above and will update such information with my practitioner as conditions change or as necessary.
I further acknowledge that, although exceptionally rare, there may be side effects to FSM treatment, such as nausea, fatigue, drowsiness, a temporary increase in pain, or a flu-like feeling from the sudden release of toxins that have accumulated in the tissues and potentially contributed to the ailment. If side effects occur, it is usually within the first 90 minutes after treatment and can last from 4 to 24 hours.
I understand and affirm that Practitioner, its owners, partners, successors, lessors, employees, and assigns hereby disclaim any and all representations of efficacy for any treatment(s), specific outcomes, or results.
I furthermore affirm that I understand the nature of the treatments imagined by FSM and Energy Healing practices and freely elect to receive those treatments. I agree that I have been given enough opportunity to ask questions and make specific requests to make my treatment time as comfortable as possible. Lastly, I agree to abide by all policies set forth by Angelic Soup, LLC., and/or its lessors.
I hereby grant Practitioner the right to alter or discontinue treatments, as warranted by the situation, at the sole discretion of Practitioner. I acknowledge that I have the right to discontinue treatments at any time and for any reason, either during a session or before my next scheduled visit.
I agree to indemnify and hold harmless Practitioner, assistants, caregivers, Angelic Soup, LLC., its successors, assigns, partners, owners, officers, and representatives, from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including court costs and attorney’s fees brought about as a result of actual or perceived harm resulting from FSM treatments.