Signed in as:
filler@godaddy.com
Signed in as:
filler@godaddy.com
I understand that yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I agree to consult with my physician about my medical conditions prior to beginning any activity program, including yoga. I understand that yoga includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. Participation in yoga classes includes, but is not limited to, participation in meditation techniques, yogic breathing techniques, and performing various yoga postures. I agree to follow all instructions that are given to me regarding all aspects of these yoga activities. (Please initial below.) As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in any yoga activities with MEREDITH SMITH and VICIOUS LIFE, LLC. (Please initial below.) I knowingly, voluntarily and expressly waive any claim that I may have against MEREDITH SMITH and VICIOUS LIFE, LLC or anyone acting on their behalf, for any injury, death or damages that I may sustain as a result of participating in yoga activities offered in person or online. (Please initial below.) MEREDITH SMITH has been engaged to provide certain yoga-related services to me. In the process of performing those services, MEREDITH SMITH may maintain, transmit, create or receive data for or from me that constitutes Protected Health Information (“PHI”). The HIPAA Notice of Privacy Practices addresses the use and disclosure of my PHI. I have carefully read the HIPAA Notice of Privacy Practices and accept its terms as indicated by typing my full name below. I acknowledge that I have read the LIABILITY WAIVER AND HIPAA NOTICE OF PRIVACY PRACTICES and agree to the terms outlined in this entire document. SIGN THIS FORM BY PRINTING YOUR FULL NAME. I, Meredith Smith, Owner of Vicious Life LLC am not qualified in diagnosing or treating any mental health or medical conditions. I am trained and certified in helping those with mental and physical challenges to gain tools to effect positive change in their lives. I do and will collaborate with mental health clinicians and medical physicians. I will provide any referrals that are not within the scope of my practice. Payment & Cancellations : Cash and credit cards are accepted. Payment is due at the beginning of the session. Arriving after the appointment time deducts time from your session. In case of late arrival or no-show, you are responsible for the full appointment fee. To cancel, or to reschedule your appointment, please contact me at least 24 hours in advance of your appointment time. Any cancellations made less than 24 hours from your appointment will incur the full cost of the session. Please note that it is my policy to keep your credit card number on file in order to cover fees for attended sessions, no-shows, canceling within 24 hours of your appointment, and other costs related to professional services.