BioMat® Consent Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Hello and Welcome to Golden Well Oasis!

Thank you so much for choosing us to partner with in your wellness journey.
I assure you that you are in loving hands!

Please complete one appointment request for each individual appointing for a BioMat Session.

Email *

FULL NAME
*

AGE
*

Best Phone Number (you will never be spammed) *

Who may I thank for referring you?

If you have any of the following conditions, it is NOT ADVISED to use the BioMat:

* organ transplants

* high fever

* cognitive disability

* skin problems on the area of use

* any heart problems

Click the box to confirm that you do not currently have any of the conditions listed above.

I confirm that I do not currently have any of the conditions listed above.

Required

Those with an EXTERNAL PACEMAKER are PROHIBITED from using the BioMat. *

I confirm that I DO NOT currently have an external pacemaker.

Required

Do not use the BioMat unless directed by a physician if you have any of the following conditions:

* immobility

* internal pacemaker/defibrillator

* Adrenal Suppression Disorders

* Addison’s Disease

* Adrenal Insufficiency

* Systemic Lupus Erythematosus

* Multiple Sclerosis (MS)

* bypass surgery

* diabetes

* high blood pressure (hypertension)

Check below to confirm that you do not currently have any of the conditions listed above or that have been advised by a physician to use the BioMat.

I confirm that I do not currently have any of the conditions listed above.

I have one or more of the conditions listed above and have been advised or cleared by my physician to use the BioMat.

Required

Do not use the BioMat unless directed by a physician if any of the following apply:

* pregnant/expecting

* infant or young children

* elderly

* recently received radiation/chemotherapy

* surgical or silicone implants

* sickness

I confirm that I do not currently have any of the conditions listed above.

One or more of the scenarios listed above apply to me and I have been advised or cleared by my physician to use the BioMat.

Required

If I have any of the conditions or scenarios listed in the 2 above questions and BioMat use has been advised by my physician, I take full responsibility for my own health and any outcomes that may be directly or indirectly impacted by my voluntary use of the BioMat and will never hold Golden Well LLC or any of it's entities, employees, volunteers or owner liable.

I have been advised by my physician to use the BioMat and agree to the statement above.

I have been cleared by my physician to use the BioMat and agree to the statement above.

Not applicable to me.

Required

If you currently have any of the following conditions, the BioMat CAN BE USED by you, but MUST be used on the Negative Ions Setting ONLY.

NO HEAT SHALL BE USED when you are experiencing the following:

* fever

* joint injuries

* insensitivity to heat/temperature

I am currently experiencing one or more of these conditions listed above.

I am currently NOT experiencing one or more of these conditions listed above.

Please tell us about a few of your goals for using the BioMat:

(check all that apply)

The healing benefits of the BioMat®’s far infrared rays and negative ion therapy

Relaxation of muscles

Increase of local circulation where applied

Temporary relief of:

Minor muscle pain

Minor joint pain and stiffness

Joint pain associated with arthritis

Muscle spasms

Minor sprains

Minor strains

Minor muscular back pain

Reduce stress and fatigue

Soothe and relax my mind and/or body

Support my immune system

Improve sleep (if associated with pain relief)

Reduce inflammation (where applied)

Increase tissue oxygen (due to increased circulation where applied)

Promote restful sleep for those with occasional sleeplessness

Aid in meditation for wellness

Other:

By checking each box below, you are stating that YOU UNDERSTAND each checked item. *

Golden Well LLC, nor any employee or volunteer is not a licensed medical physicians. We are not diagnosing, treating or practicing medicine in any way, shape or form.

Golden Well LLC, GoldenWell4U website, and Golden Well Oasis presentations and consulting sessions conducted by Angela Goldthwaite or any associates, employees or volunteers of Golden Well LLC are not licensed medical doctors, dietitians or nutritionists and therefore are not diagnosing, treating, curing, mitigating, preventing, practicing or prescribing medical treatment for any type of disease or medical condition.

Golden Well LLC, GoldenWell4U website, and Golden Well Oasis presentations, hand-outs and consulting sessions given or conducted by Angela Goldthwaite or any associates, employees or volunteers of Golden Well LLC are for information purposes only. It is not intended to substitute for medical treatment or diagnosis and is not monitored by the FDA.

Before beginning any type of natural, integrative or conventional treatment regimen, it is advisable to seek the advice of a licensed healthcare professional.

I understand that BioMat results may vary and are not guaranteed.

Required

Waiver and Discharge of Liability - Check the box once you have read, understand and agree to the following: Golden Well LLC, GoldenWell4U website, and Golden Well Oasis presentations and wellness consulting sessions conducted by Angela Goldthwaite or any associates, employees or volunteers of Golden Well are not medical doctors, dietitians or nutritionists and therefore are not diagnosing, treating, curing, mitigating, preventing, practicing or prescribing medical treatment for any type of disease or medical condition. The Golden Well LLC, GoldenWell4U website, and Golden Well Oasis presentations, hand-outs and consulting sessions given or conducted by Angela Goldthwaite or any associates, employees or volunteers of Golden Well are for informational purposes only. It is not intended to substitute for medical treatment or diagnosis and is not monitored by the FDA. Golden Well LLC, Angela Goldthwaite or any associates, employees or volunteers of Golden Well LLC are not liable and are released from all claims of harm for any injury of any kind, including but not limited to: mental, emotional, physical, medical, spiritual, energetic, social, financial, relational, etc. Before beginning any type of natural, integrative or conventional treatment regimen, it is advisable to seek the advice of a licensed healthcare professional. Any controversy or claim arising out of this Agreement shall be settled by binding arbitration. *

I understand and take full personal responsibility for myself, my actions, my health and the outcome of the information received from Golden Well LLC (Angela Goldthwaite or any associates, employees or volunteers of Golden Well LLC). Any application of the information provided is at my sole discretion and is my sole responsibility of risk and liability.

Required

By typing your name below, you agree that you have completed the above consent form in truth to the best of your knowledge.

Thank you for choosing Golden Well Oasis.

Type your NAME below.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms