Intake Form Terms
While Five Rivers Yoga will not share your information with any third parties, note that HIPAA regulations do not apply and this form does not use HIPAA-secure transmission or storage for data.
Agreement: PLEASE READ CAREFULLY BEFORE SUBMITTING/SIGNING.
[Form created: 2/11/2016, updated: 7/7/2016]
- DISCLOSURE STATEMENT: Health Freedom Act, California SB-577. I understand that Rachel Lanzerotti is a practitioner of Yoga Therapy. Yoga Therapy may include breathing practices, movement, meditation and daily mindfulness, and lifestyle coaching. As part of Yoga Therapy, Rachel may suggest Ayurvedic practices, which shift the body towards health and balance. Ayurveda is an Indian mind-body health system and uses dietary recommendations and herbal remedies. Rachel is not a licensed physician, nor are Yoga Therapy services licensed by the state. Rachel Lanzerotti has certification in Yoga Therapy from the Essential Yoga Therapy Therapist Training Program, in Fall City, WA and is a member of the International Association of Yoga Therapists (IAYT). Her method of treatment, Yoga Therapy, is an alternative or complementary form of healing arts. Under Sections 2053.5 and 2053.6 of California’s Business and Professions Code, I understand that Rachel can offer me these services, subject to requirements and restrictions that are described fully in the document entitled “California State Senate Bill SB 577 – What It Means for Patients.” If I ever have any concerns about the nature of my treatment, I will discuss them with Rachel. I understand that she recommends that I inform my medical doctor or other primary care provider that I am participating in Yoga Therapy, especially if I am under medical care for any condition. California state law requires that I acknowledge receipt of this information and receive a copy. Rachel will keep the original in her records for at least 3 years.
- I understand that I must judge my own capabilities with respect to practicing yoga and meditation. I recognize that yoga may involve physical exertion. By my participation, I agree to assume full responsibility for any risks, injuries, or damages, known or unknown that I might incur in such practice.
- I understand that it is my responsibility to consult with a physician prior to and regarding my participation in yoga and meditation. I represent and warrant that I have no medical condition that would prevent my full participation. I acknowledge that it is my responsibility to inform the instructor, when I begin a class, of any injury or other condition that might affect my ability to participate, and to inform the instructor immediately if an injury occurs during class. During a class, if at any time I feel that instructions or class activities present any risk of injury to me, or if I feel tired or otherwise unable to perform class activities, I will inform the instructor and refrain from activities in question.
- If I am pregnant, I assert and attest that I am participating in yoga and/or meditation classes, with my doctor’s explicit approval. I acknowledge that I am participating in yoga and/or meditation classes at my own risk, and that it is my responsibility and my doctor’s responsibility to determine safe parameters of my participation, whether or not I inform the class instructor that I am pregnant.
I have read and understand the above Disclosure Statement about the Yoga Therapy services offered by Rachel Lanzerotti and her training and education. I understand the nature of services to be provided, that Rachel Lanzerotti is not a licensed physician and that Yoga Therapy services are not licensed by the state. I understand it is my responsibility to maintain a relationship for myself with a medical doctor. I have consented to use the services offered by Rachel Lanzerotti, and agree to be personally responsible for her fees in connection with the services provided to me.
By submitting this form, I acknowledge that participation in yoga and/or meditation classes exposes me to a possible risk of personal injury. I forever release, and waive, and discharge claims based on, and covenant not to sue based on, any injury sustained in or in connection with yoga and/or meditation classes operated or taught by Rachel Lanzerotti and her agents or Five Rivers Yoga, LLC (Released Parties). I knowingly, voluntarily, and expressly make such release, waiver, discharge, and covenant, for the benefit of Released Parties, as a condition of participating in the yoga and/or meditation classes in question, and do so on behalf of myself, my spouse, and successors, heirs, assigns, and creditors.
By clicking AGREE, I am electronically signing consent and will retain a copy of Rachel’s Client Disclosure form and this Agreement.