Sample Consent for Treatment

IN CONSIDERATION OF the risks that exist while participating in healing sessions (hereinafter the “Activity”) due to having received experimental treatments; and

IN CONSIDERATION OF my desire to participate in said Activity and being given the right to participate in same;

I HEREBY knowingly and voluntarily enter into this Agreement and waive any and all rights, claims or causes of action of any kind arising out of my participation in the Activity; and

I HEREBY release and forever discharge SUSAN E. SEIDMAN, HOLISTIC HEALTH PRACTITIONER, office located in Morrisville, North Carolina 27560, from any injury or side effect that I may suffer as a direct result of my participation in any aforementioned Activity.

I AM VOLUNTARILY PARTICIPATING IN THE AFOREMENTIONED ACTIVITY AND I AM PARTICIPATING IN THE ACTIVITY ENTIRELY AT MY OWN RISK. I AM AWARE OF THE RISKS ASSOCIATED WITH HAVING PREVIOUSLY RECEIVED EXPERIMENTAL INJECTION(S).  I ASSUME ALL RELATED RISKS, BOTH KNOWN AND UNKNOWN TO ME, OF MY PARTICIPATION IN THIS ACTIVITY.

I HEREBY ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS DOCUMENT AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY AND CONSENT FOR TREATMENT.  I EXPRESSLY AGREE TO RELEASE AND DISCHARGE Susan E. Seidman, Holistic Health Practitioner, FROM ANY AND ALL CLAIMS OR CAUSES OF ACTION AND I AGREE TO VOLUNTARILY GIVE UP OR WAIVE ANY RIGHT THAT I OTHERWISE HAVE TO BRING A LEGAL ACTION AGAINST SUSAN E. SEIDMAN FOR PERSONAL INJURY.

I agree that this document shall be governed for all purposes by North Carolina law, without regard to any conflict of law principles.

THIS WAIVER AND CONSENT FOR TREATMENT SHALL REMAIN IN EFFECT FOR THE DURATION OF MY PARTICIPATION IN THE ACTIVITY, DURING THIS INITIAL AND ALL SUBSEQUENT EVENTS OF PARTICIPATION.

THIS AGREEMENT was entered into at arm’s length, without duress or coercion, and is to be interpreted as an agreement between two parties. Both the Participant and Susan E. Seidman acknowledge that this agreement is clear and unambiguous as to its terms, and that it will be interpreted based on the language in accordance with the purposes for which it is entered into.

In the event of an emergency, please contact the following person(s) in the order presented:

Emergency Contact                               Contact Relationship                            Contact Telephone

        __________________________________                 _____________________________                        _____________________________                               

I, THE UNDERSIGNED PARTICIPANT, AFFIRM THAT I AM OF THE AGE OF 18 YEARS OR OLDER, AND THAT I AM FREELY SIGNING THIS AGREEMENT. I CERTIFY THAT I HAVE READ THIS AGREEMENT, THAT I FULLY UNDERSTAND ITS CONTENT AND THAT THIS AGREEMENT CANNOT BE MODIFIED ORALLY. I AM AWARE THAT THIS IS A CONTRACT AND THAT I AM SIGNING IT OF MY OWN FREE WILL.

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(Participant’s Name – Printed)                                                                                             (Date)

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(Participant’s Signature)