Relaxation & Wellbeing with 5NP ear acupuncture
Event Address: 5-35 51st Ave, Long Island City
Contact us at:
First and last name:
How did you hear about this event?
Is this your first time receiving ear acupuncture?
Is there anything you'd like your therapist to know before you receive ear acupuncture?
RELEASE AND WAIVER
PLEASE READ CAREFULLY AND UNDERSTAND FULLY YOUR AGREEMENT TO PARTICIPATE IN THE RELAXATION & WELLBEING WITH 5NP EAR ACUPUNCTURE HEALING SPACE. I UNDERSTAND THAT THIS TYPE OF THERAPY ENTAILS THE INSERTION OF STERILE ACUPUNCTURE NEEDLES IN EACH EAR. IN CONSIDERATION FOR BEING PERMITTED TO PARTICIPATE IN THIS ACTIVITY, I AGREE AS FOLLOWS : 1. Assumption of Risk - I understand that the 5NP ear acupuncture protocol involve the insertion of 5 sterile disposable thin needles in each ear. That the proposal is to keep the needles for at least 30 minutes, but that I can always ask, anytime, for the removal of some or all the needles. That no specific outcome is guaranteed after the 5NP protocol session. That even though its not common, the needle insertion in the outer ear may have secondary effects such as: bruises, minimal bleeding, dizziness, and/or light pain/discomfort in the needled area. I agree that I have had the opportunity to consult with my health care provider to ask for the safety of this type of therapy. I freely and voluntarily choose to assume all risks associated with, or which may result from, participating in the Relaxation & Wellbeing with 5NP ear acupuncture. 2. Release of Liability - I agree, for myself and my heirs, to fully and forever discharge Daniel Orsini, Lourdes Hernández, and/or their agents, from any and all liabilities, claims, demands, actions and causes of action whatsoever whether known or unknown based upon any harm or injury caused by negligence or any other reason, on the account of, or in any way resulting from, or in any way connected with my participation in the Relaxation & Wellbeing with 5NP ear acupuncture healing space. 3. Covenant Not to Sue - I agree, for myself and my heirs, to never sue or make any claim against, Daniel Orsini, Lourdes Hernández and/or all of their agents, nor to initiate or assist in the prosecution of any claim for damages or any other cause of action which I or my heirs may have reason to believe resulted in harm or injury arising from my participation in the Relaxation & Wellbeing with 5NP ear acupuncture healing space. I HEREBY ACKNOWLEDGE THAT I HAVE FULLY READ EACH OF THE ABOVE PROVISIONS AND FULLY UNDERSTAND AND AGREE WITH EACH PROVISION, AND ACKNOWLEDGE THE SAME BY COMPLETING THE SIGN IN SHEET.
I agree and would like to register for the therapy.
I disagree and do not want to register for the therapy.
Preferred Payment Method:
Have you submitted payment? (sliding scale $25 to $45)
No, but will soon!
WHAT TO BRING:
Comfortable clothing and relaxation intention.
Thank You! See you soon :)
Please note, your spot is not reserved until you've submitted payment.
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service