VibraSound® Session Release Form
Note: This is a sample form only. Each practitioner is required to have a release form compatible with their state and local laws.
The technology used in the VibraSound Relaxation Studio incorporates light, sound, color, aroma, and vibration to assist in creating a state of profound relaxation. It is classified as a learning and entertainment technology and is not approved of, or disapproved of, by any governmental or other regulatory agencies.
WARNING: INDIVIDUALS WITH PHOTOSENSITIVE EPILEPSY OR OTHER NERVE CONDITIONS SENSITIVE TO FLICKERING LIGHT SHOULD NOT USE THE SENSORIUM BECAUSE A SEIZURE MAY OCCUR. INDIVIDUALS WHO HAVE NEVER SUFFERED AN EPILEPTIC SEIZURE MAY NEVERTHELESS HAVE AN UNDETECTED EPILEPTIC CONDITION. IF YOU ARE NOT WILLING TO TAKE THIS RISK DO NOT USE THE SENSORIUM. IF YOU HAVE A PERSONAL OR FAMILY HISTORY OF EPILEPSY OR ANY OTHER CONDITION SENSITIVE TO FLICKERING LIGHT, ARE UNCOMFORTABLE WITH BRIGHT LIGHT, HAVE A HEART CONDITION, OR ARE UNDER THE RESTRICTIVE CARE OF A PHYSICIAN FOR ANY SERIOUS MEDICAL CONDITION, YOU SHOULD CONSULT A QUALIFIED MEDICAL PROFESSIONAL BEFORE USING THE SENSORIUM. IMMEDIATELY DISCONTINUE USE OF THE SENSORIUM IF YOU EXPERIENCE ANY OF THE FOLLOWING SYMPTOMS: INVOLUNTARY MOVEMENTS, DISORIENTATION, EYE OR MUSCLE TWITCHING, CONFUSION, DIZZINESS, CONVULSIONS OR NAUSEA.
IN ADDITION, YOU SHOULD NOT USE THE EQUIPMENT IF YOU:
· ARE UNDER PROFESSIONAL CARE FOR ANY SERIOUS MEDICAL CONDITION.
· ARE UNDER THE INFLUENCE OF ALCOHOL OR DRUGS.
· ARE WEARING A PACEMAKER OR OTHER ELECTRONIC MEDICAL DEVICE.
· ARE IN THE FIRST TRIMESTER OF PREGNANCY.
· ARE SENSITIVE TO FLASHING LIGHTS.
· HAVE EVER RECEIVED ANY SERIOUS HEAD TRAUMA.
· SUFFER FROM ANY SERIOUS PSYCHOLOGICAL DISORDERS.
YOU SHOULD IMMEDIATELY DISCONTINUE THE USE OF THE EQUIPMENT IF YOU BECOME UNCOMFORTABLE OR EXPERIENCE ANY OF THE FOLLOWING SYMPTOMS: INVOLUNTARY MOVEMENTS, DISORIENTATION, MUSCLE TWITCHING, CONFUSION, DIZZINESS, OR NAUSEA.
In exchange for the right to use the equipment at the VibraSound Relaxation Studio the undersigned states:
I agree to release and hold harmless InnerSense, Inc., Microfirm, Inc., their employees, and agents from all claims, damages, and other liabilities, present or future, whether or not known or anticipated, that may result from or arise out of the undersigned's use or intended use of the premises, facilities, and equipment at The VibraSound Relaxation Center. I have read and understand the foregoing waiver of liability. (If the participant is under the age of 16, the undersigned parent or guardian hereby consents and agrees to be bound by this release.)
Name (Print) ________________________________________________________________
Street City State Zip
Date of Birth ____________________ Signature _________________________________
Parent or Guardian Signature: ___________________________________________________