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Consent for Consultation/Liability Release Waiver

Consent for Consultation and Liability Release Waiver

Jackie Shea and Eva Hagberg Fisher aka Wellness Companions are not physicians or psychologists, and the scope of their consultation services does not include treatment or diagnosis of specific illnesses or disorders.  If I, the client, suspect I may have an ailment or illness that may require medical attention, then I am 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 I am taking and not for Jackie Shea and Eva Hagberg Fisher aka Wellness Companions to judge the appropriateness of the medication.  Any change in prescription or dosage is a decision I makes with my physician.

By signing below, I acknowledge that I understand that Jackie Shea and Eva Hagberg Fisher are health consultants and not physicians, and that I should see a doctor if I think I have a medical condition.  Jackie Shea and Eva Hagberg Fisher aka Wellness Companions will not be held liable for failure to diagnose or treat an illness, nor will they be liable for failure to prevent future illness.

I hereby give my consent to receive wellness support from Jackie Shea and Eva Hagberg Fisher, and I acknowledge and agree that I am doing so at my own risk. My health and safety with respect to such services are my sole responsibility. My decision to receive these services is voluntary, and I know of, understand and assume any and all risks associated therewith. 

I release and discharge Jackie Shea and Eva Hagberg Fisher, aka Wellness Companions, from any and all claims, liabilities, damages, actions, or causes of action arising from the consultation received hereunder, including, without limitation, any damages arising from acts of active or passive negligence on the part of the consultant, to the fullest extent allowed by law. 

I acknowledge that I have read, and understand the release and indemnification provisions set forth, and agree to such terms. By signing this release, I hereby waive and release my consultants from any and all liability, past, present, and future relating to the services provided. I agree and understand this consent will apply to and govern the current and all future sessions performed by Wellness Companions. 

I agree to actively participate, to the best of my ability, in my own healing and growth process. 

 

 

Client’s Signature__________________________________Date__________