Liability Waiver for Clients of Shameen Miller
ACKNOWLEDGEMENT AND RELEASE OF LIABILITY
By electronically signing the form below, “I Accept”:
I acknowledge that my participation in fasting coaching is expressly conditioned on my agreement to each of the terms of this document. I acknowledge and agree as follows:
You understand that “Service" received by Shameen Miller (“Coach”) is not offered as a substitute for professional medical care and are not intended to diagnose, treat, or cure any medical conditions. You understand that the Coach is not acting as a medical professional. Shameen Miller is not a physician or psychologist, and the scope of her nutrition counseling does not include treatment or diagnosis of specific illnesses or disorders. If you, the client, suspect you may have an ailment or illness that may require medical attention, then you are encouraged to consult with a licensed physician without delay. Only a licensed physician can prescribe drugs. Any mention of drugs in the course of consultation is only for the purpose of providing a complete history of drugs that the client is taking and not for Shameen Miller to judge the appropriateness of the medication. Any change in prescription or dosage is a decision the client makes with his or her physician.
I affirmatively state that I have disclosed any and all known medical or genetic conditions, medications I use, and any significant personal or family medical history. Any recommendations that I follow for changes in diet, including but not limited to the use of food supplements, are entirely my choice and my responsibility. I am knowingly assuming any risk associated with nutritional counseling.
By purchasing any Service provided by the Coach, you understand that Service is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care, or substance abuse treatment, and you will not use it in place of any form of therapy.
You understand and agree that you are fully responsible for your well-being during coaching sessions, and afterwards, including your choices and decisions.
By purchasing and participating in any Service provided by the Coach, you signify that you have been advised that an examination by a physician should be obtained by you prior to commencing a wellness, fitness and/or exercise program, or initiating a substantial change in dietary guidelines or the amount of regular physical activity performed. If you have chosen not to obtain a physician’s consent prior to beginning a Service with Coach, you hereby agree that you are doing so solely at your own risk. If you do not agree, you must contact firstname.lastname@example.org immediately and stop following any Service provided by Coach. In any event, by purchasing a Service, you acknowledge and agree that you assume the risks associated with any and all wellness and fitness related activities and/or exercises in which you participate. You acknowledge that Services provided by Shameen Miller are NOT medical advice and are NOT to replace the advice of health care professionals.
You have been informed of, understand and are aware that any wellness, exercise, or fitness activities may cause injury. You understand that there is an inherent risk of injury when choosing to participate in any wellness, exercise or fitness activities. You also have been informed of, understand and are aware that any wellness, exercise and/or fitness activities involve a risk of abnormal changes in blood pressure, fainting, and a remote risk of heart attack, stroke, other serious disability or death. Your participation is a voluntary activity in all respects and you assume all risk of injury (including death), illness, damages or loss that may result from such participation in any and all activities arising out of, connected with, or in any way associated with wellness activities. You acknowledge that participation in these activities is voluntary.
You understand that all comments and ideas offered by the Coach are solely for the purpose of User in achieving defined goals. The User has the ability to give informed consent, and hereby gives such consent to the Coach in assisting User in achieving such goals.
You understand Coach will protect User information as confidential unless User states otherwise in writing. If User reports child, elder abuse or neglect or threatens to harm User or someone else, the User understands that necessary actions will be taken and User’s confidentiality agreement is limited in this capacity.
I have read and fully understand this Acknowledgement and Release of Liability set forth above, including the release of all claims, including claims for the negligence of the Released Parties.
I am 18 years old or older. I understand that my signed waiver will be retained in my client personnel file. This document is binding upon me and my heirs, children, wards, personal representatives and anyone else entitled to act on my behalf.
By electronically signing the form below, and clicking"I agree to the terms & conditions" that I acknowledge the Shameen Miller Liability Waiver.