Minor Intake Form Minor Intake Form Minor Intake Form Required AuthorizationsConsent(Required) I have read and I agree to the In-Person and Remote Wellness Services Policies and Procedures belowWelcome to Vishoka Wellness, LLC (“Vishoka Wellness,” “we,” “us,” “our”)! Vishoka Wellness offers both in-person and remote classes for individuals and groups looking to improve their health through exercise, breathing techniques, stress management, meditation, mindfulness techniques, yoga, sleep hygiene, dosha evaluation, and gut health recommendations/nutrition; as part of these offerings, we also provide additional wellness programs covering various wellness-related topics (collectively, “Wellness Services”). We are passionate about helping our clients live a healthy lifestyle through our various Wellness Service offerings. Please carefully review this document as it sets forth the terms of our relationship while receiving Wellness Services. If you agree to these terms, sign, and date below. Wellness is not Physical Therapy Although our principal is a licensed physical therapist, Wellness Services are neither physical therapy nor any licensed service. This means that our work together does not create a provider-patient relationship between you and us. Wellness Services, including related techniques, poses, postures, routines, recommendations and exercises, may not be appropriate for everyone. If you have concerns about a medical condition, please schedule an appointment with us or another medical provider. Wellness Services are not a substitute for medical advice. Wellness Services do not include “a form of health care that prevents, identifies, corrects, or alleviates acute or prolonged movement dysfunction or pain of anatomic or physiologic origin.” Communications Policy By providing us with your contact information, or by initiating communication with us through email or phone, you authorize us to email, call, leave voicemails, and send text messages using that information. We will use this information for non-marketing purposes, including reminders, invoicing updates, and to address questions. You further understand and agree that communicating with us by unencrypted emails and text messages may not be secure. Payment and Cancellation Policy All sessions, workshops, classes are prepaid, meaning payment is due before your class time. We do not reimburse you for sessions that you miss or cancel. We accept credit and debit cards. We do not accept insurance as Wellness Services are generally not covered by insurance. Thus, we do not guarantee that your insurance will cover any portion of our services or provide you with any reimbursement. You are solely responsible for all fees. We do not offer makeup sessions for any of our programs, classes/sessions and workshops. Please read FAQ section on our website to find out more about our makeup session policy. Regarding online services, just like with an in-person session, we have reserved a time for you. If you need to cancel or reschedule your Wellness Services session, please contact us during business hours and at least 24 hours prior to your scheduled appointment. For Monday classes, we ask that you cancel by 12:00 p.m. on the previous Friday so we can offer that time to another client. If you fail to attend a class, we do not offer makeup sessions. Other Policies Substance Abuse and Sobriety. We will not provide Wellness Services if you are under the influence of recreational drugs or alcohol during our sessions. If you come to a session under the influence of recreational drugs or alcohol, we will conclude the individual session or demand you leave the group class. We may also evaluate the feasibility of continuing our work together. Indemnification and Assumption of Risk As a condition for receiving Wellness Services, you agree to indemnify us against all claims, liabilities, losses, damages, suits, costs, and expenses (including reasonable attorney’s fees) to the greatest extent permitted by law and as they relate to your failure to follow our instructions, communicate to us about any problems you encounter during our services, or update us about changes to your health, and you agree to assume all risk of property damage, injury, or death associated with such failures. No Warranty Although we aim to provide valuable and correct guidance, we make no warranty as to the effectiveness of our Wellness Services for you. Further, we believe the information we provide is accurate. However, we cannot guarantee such accuracy as we are not the originators of the underlying data used in the interpretation. Accordingly, we disclaim all liability to any party for any direct, indirect, implied, punitive, special, incidental, or other consequential damages arising directly or indirectly from our Wellness Services. Wellness Services are provided as-is, without additional warranty. Disclaimer Vishoka Wellness, LLC (“we,” “our,” or “us”) owns the original educational materials presented as part of this wellness program, which includes all sessions, recommendations, worksheets, workshops or any program with us. Your activities, communications, and involvement with this wellness program do not create a provider-patient relationship between you and us, and they do not create any duty for us to follow up with you. We reserve the right to process, retain, and monitor all in-person and electronic communications, including personally identifiable information related to this wellness program. Private messages, reactions to content, and comments about the program and the material may all be retained in a manner of our choosing. The information provided as part of this wellness program is for educational and informational purposes only. It is not medical advice, physical therapy advice, or any other licensed healthcare advice. While this wellness program will touch on health and wellness-related concepts, the materials do not replace the advice of a licensed healthcare provider who is familiar with your personal medical history. If you have individualized health concerns or questions about diagnosis or treatments, please contact your healthcare provider. In a medical emergency, call 911. If you have questions about our services, please contact us directly. Summary of Remote Wellness Services Privacy and Security of Remote Technology Remote technology platforms incorporate network and software security protocols to protect your confidentiality. Consistent with privacy laws, our technology includes safeguards intended to secure and ensure the integrity of client information. We utilize technology that: (i) complies with the relevant safety laws, rules, regulations, and codes for technology and technical safety for devices that interact with clients; and (ii) offers sufficient quality, size, resolution, and clarity such that we believe we can safely and effectively provide Wellness Services through a remote platform. Although you are not receiving medical care nor physical therapy services from us, we work to comply with applicable state and federal laws, which may still require us to protect the confidentiality and privacy of certain medical and personal information. We have implemented policies to ensure our compliance with these requirements. Benefits, Risks, and Alternatives We strive to explain the benefits, risks, and alternatives to you about Wellness Services being delivered remotely. Benefits. Technology platforms can facilitate high-quality Wellness Services in a convenient and effective manner. Risks. The risks may include, but are not limited to, the following: (i) information transmitted may not be sufficient (for example, poor resolution of images); (ii) technical deficiencies or failures; and (iii) your information could be accessed or intercepted by an unauthorized person. Alternatives. You can choose not to receive or halt Wellness Services delivered via our remote platform.For Minors: Legal Guardian or Power of AttorneyLegal Guardian Name(Required) First Last Authority Type(Required) Minor Client Name(Required) First Last Relationship to Minor Client(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Mobile Phone(Required)Home PhoneIf applicable, please attach applicable legal documents establishing the above relationship. Drop files here or Select files Max. file size: 2 MB, Max. files: 3. Consent for Emergencies I have read and agree to the statement below.In addition to calling 911 if appropriate, by signing this agreement, you authorize us to contact the above legal guardian or power of attorney if the client is experiencing a health emergency. We will disclose only the minimum amount of information related to the emergency.Media Release and Marketing AuthorizationAcknowledgement(Required) I have read the Media Release and Marketing Authorization belowThank you for allowing Vishoka Wellness, LLC (referred to throughout this document as “Vishoka Wellness,” “us,” and “we”) to include you in our media for use online, via social media, and for marketing purposes. Please review this Media Release and Marketing Authorization (“Release”) carefully before signing. It establishes how we may use video recordings, audio recordings, photographs of you (including biometric identifiers), your first and last names, age, profession, and health information (collectively “Media-Related Information”) for any marketing purpose, on all forms of social media, and used or otherwise distributed on the Internet generally. By signing this document, you will help us expand our reach and make others aware of Vishoka Wellness’s services. This is a legal document. Signing it is entirely voluntary. › Biometric and Other Privacy Laws. To the extent that a photograph (digital or otherwise) or video constitutes or contains biometric identifiers, you confirm that this Release: (i) informs you or your legally authorized representative in writing that a biometric identifier or biometric information may be collected or stored; (ii) informs you or your legally authorized representative in writing of the specific purpose and length of term for which a biometric identifier or biometric information may be collected, stored, and used; (iii) constitutes Vishoka Wellness’ receipt of a written release executed by you or your authorized representative of the biometric identifier or biometric information; (iv) constitutes your consent or your legally authorized representative’s consent to disclosure and redisclosure of the biometric identifier or biometric information; (v) you acknowledge that Vishoka Wellness stores, transmits, and protects from disclosure all biometric identifiers and biometric information using the reasonable standard of care within its industry; and transmits and protects from disclosure all biometric identifiers and biometric information in a manner that is the same as or more protective than the manner in which it stores, transmits, and protects other confidential and sensitive information. To the extent that the other privacy laws and their regulations apply to the Media-Related Information, you acknowledge that this Release constitutes your informed consent and authorization to disclose the Media-Related Information for Vishoka Wellness’ marketing purposes. › Purpose for Collection.Vishoka Wellness collects video and audio recordings and photographs (including digital photographs) for Vishoka Wellness’ marketing. › Right of Revocation and No Compensation. You acknowledge and agree that you may revoke this authorization at any time by notifying Vishoka Wellness in writing at the email address listed above. However, once the Media-Related Information is published, Vishoka Wellness has no control over subsequent third-party redisclosure; thus, the Media-Related Information can never be removed entirely from the Internet. This means that even if you revoke this consent, Vishoka Wellness will be unable to remove the Media-Related Information completely. Such revocation will only apply to future disclosures. You further acknowledge and agree that you will not receive compensation for signing this document, being video and audio recorded or photographed, or for any use of the Media-Related Information; that you have no right to inspect or approve the Media-Related Information prior to its disclosure; and that after you sign this document, the Media-Related Information will no longer be protected by medical privacy laws. › Retention Schedule and Data Storage.Vishoka Wellness shall retain biometric information only until the first of the following occurs: (i) the initial purpose for collecting or obtaining such biometric data has been satisfied, or (ii) within three years of your last interaction with Vishoka Wellness. Vishoka Wellness stores, transmits, and protects from disclosure of all biometric identifiers and biometric information using the reasonable standard of care within its industry; and transmits and protects from disclosure of all biometric identifiers and biometric information in a manner that is the same as or more protective than the manner in which it stores, transmits, and protects other confidential and sensitive information. › Grant of Right and Agreement to Indemnify. You hereby grant Vishoka Wellness the right and permission to use the Media-Related Information to reproduce, edit, exhibit, project, display, copyright, and publish, in whole or part. You hereby indemnify Vishoka Wellness against any damages, losses, liabilities, judgments, costs, or expenses (including reasonable attorney fees and costs) arising from any third-party claims that relate to Vishoka Wellness’ use of the Media-Related Information. ›Acknowledgment and Agreement. By signing this Release, you agree and understand that the Media-Related Information will no longer be protected by privacy laws or protected from redisclosure without your consent and (ii) that you are legally bound by this document.Do you consent to the Media Release and Marketing Authorization?(Required) I consent I do not consent. I understand I must follow up by email to info@vishokawellness.com to provide written notice that I decline my consent. Signature(Required) Your full name typed in this field will serve as your signature to everything you have indicated above.
