EYT Waiver and Release Name * First Name Last Name Address * City * State * Zip * Phone * (###) ### #### Email * Emergency contact name * Relationship to client * Emergency contact email and phone number * Primary physician name and phone number * I, (enter name below) hereby agree to the following: * I understand that yoga therapy is provided for the basic purpose of stress reduction in the form of breath work, relief of muscular tension/weakness through movement, and to support healing the connection between mind, body and spirit, through dialogue and exploration of the teachings of yoga. I further understand that yoga therapy should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, or other qualified medical specialist for mental or physical ailments that I am aware of. I understand that yoga therapists are not qualified to perform skeletal adjustments, diagnose and/or prescribe, and that nothing said in the course of the session should be construed as such. Because the physical practice of some yoga postures is contraindicated under certain conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I forget to do so. Due to COVID-19, I understand that all private sessions, public workshops, and classes provided by EYT will be held on-line rather than in person. I understand that public programs may be recorded and utilized on social media, the EYT website for promotional purposes, or uploaded to the EYT digital library for future sales. While these recordings will endeavor to spotlight the instructor, I hereby consent to the use of my image as it may appear in any such photograph or video. * I understand that yoga therapy offers psycho-emotional support and in the event that I indicate intention to harm myself or another, I give permission to my yoga therapist to contact my emergency contact person and/or physician to ensure my health and safety. * Essential Yoga Therapy, explanation of fees for service: Patients are responsible for full payment at the time services are rendered. I currently accept check or cash only. All professional services rendered are charged to the patient receiving care. I will supply you with a statement, report, or other document if applicable to help you receive reimbursement from a third party. Currently, most insurance does not cover yoga therapy. Yoga Therapy Session Length and Cost: 60 minutes: $120 90 minutes: $180 Initial Consultation Fee (2 hour appt.) $210 4 Session Package (Includes initial consult + 3 hrs. of follow-up: $495 Missed/Cancellation Appointment Policy The EYT office requires 12-hour notice of cancellation of Yoga Therapy or Breathing Lite Appointments. Appointments missed or cancelled without sufficient notice will be charged the cost of a one-hour session (with the exception of the initial consult for which the charge will be the full $210) I accept full responsibility for payment for missed appointments. I have read, understood, and agreed to the fees and payment obligations as listed above. * I understand that yoga is a physical exercise and acknowledge that participation in yoga therapy involves some risk. I understand that hands-on adjustment and touch may be part of the therapeutic process offered by my therapist. I agree to release, hold harmless and indemnify Essential Yoga Therapy and the therapist from all claims including negligence, which arise out of participation in EYT practices. This agreement shall be construed in accordance with, and governed by, the laws of the State of Washington and that all actions, suits, claims and proceedings relating to this agreement shall be brought in a court of competent jurisdiction located in Washington. In case any provision of this agreement shall be held invalid, illegal or unenforceable, it shall not affect any other provision of this agreement and this agreement shall be construed as if such provision had never been contained herein. I acknowledge that I have carefully read this agreement and fully understand its contents. I voluntarily and knowingly agree to the terms and conditions stated herein. I am aware that by signing this agreement, I am giving up substantial rights, including my right to sue and certain legal rights my heirs, next of kin, executors, administrators and assigns may have against any Released Party. * Electronic signature * “By checking this box and typing my name below, I am electronically signing this consent form * Yes, I consent No, I do not consent Today's date * I would like to receive the EYT Newsletter via e-mail to stay current on opportunities to attend workshop, therapeutic classes and clinics that are being offered in the area. * Yes No Thank you!
