RELEASE FORM
I HEREBY ASSUME ALL THE RISKS OF PARTICIPATING AND/OR
VOLUNTEERING IN THIS ACTIVITY, including by way of example and not limited
to, any risks that may arise from negligence on the part of the persons being released,
from dangerous or defective equipment or property owned, maintained, or controlled by
them, or because of their possible liability without default.
I understand body wraps do not cure or heal disease or ailments; it pulls toxins from the
body allowing the body to rebalance and accelerate its own self-detoxification.
I INDEMINFY, HOLD HARMLESS, AND PROMISE NOT TO SUE PRIORITY
HEALTH CHIROPRACTIC, INC., ITS EMPLOYEES, AGENTS OR CONSULTANTS.
I certify that I have read this document, and I fully understand its contents. I am
aware that this is a release of liability and a contract and I sign it of my own free
will.
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SIGN NAME
DOCTOR RELEASE FORM
(for patients that take blood pressure medication)
One of your patients wishes to schedule a body wrap at Priority Health (201 E. Veterans
Pkwy, Yorkville, Illinois 60560). Since they are on blood pressure medication, we need
to obtain permission from the doctor who prescribes their blood pressure medication. Our
formula contains niacinamide, which may interfere with blood pressure/blood pressure
medication.
Here is some more information on the wrap:
The Herbalogica Body Contour Wrap was originally developed by a bio-chemist from the
UCLA Medical group. Our parent corporation bought the formula to this process in 1980
and has been used by medi-spa and medical for the last 30 years. This wrap process was
originally formulated to encourage circulatory and lymphatic flow in patients. It was
meant for those suffering from diabetes or any disease that inhibited circulation,
especially in the lower extremities. Research showed that because of the increased flow
of both the lymphatic and circulatory systems, the patient also was cleansing the tissues.
This in turn caused healthy inch loss through internal cleansing.
Not only did the body benefit internally, but the external benefits of contouring and inch
loss made this wrap ideal for the medical and medi-spa industries. Inch loss, diminishing
of cellulite, and body contouring can be permanent and completely safe. The herbal
formulation works externally to internally. This program aids in the removal of wastes
that have become trapped in vulnerable parts of our bodies. It is basically a cleansing
process of the tissue underneath the skin and helps restore elasticity to loose, flabby skin.
It does not dehydrate and age the skin.
The cream contains .25 percentage of formula, Niacinamide, along with Aloe Vera, Ivy
extract, Spiralea extract, Clematis extract, Avocado pulp, Tea extract, Bladderwrack,
Horsetail extract, Allantoin, Garlic oil and Cassia.
I, ________________________ (Doctor’s name), am granting permission for my
patient ________________________ (patient’s first and last name) to receive a body
wrap at Priority Health (201 E. Veterans Pkwy, Yorkville, Illinois 60560).
PRINT NAME DATE
SIGN NAME