By checking this box, I, the Client, seek the massage therapy services of ZMT, LLC, (“ZMT”). I understand that ZMT is not a hospital-based office, nor a medical clinic, nor are they providing any form of medical care, and that should I need any medical assistance of any kind, I must establish and/or maintain a relationship with my primary care physician and/or other physicians appropriate to any of my condition(s) and situation, if and as applicable. I understand that no claims, representations, or guarantees have been made to me regarding my treatment or prognosis, and that ongoing treatment with ZMT may not improve any health conditions and/or medical problems I may have.

I understand and expressly agree that all such treatments provided by ZMT are voluntary and elective, and that I may elect to forgo any and all treatments suggested by ZMT.  I further acknowledge and expressly agree that I knowingly elect to undergo all such treatments, and thereby knowingly assume all of the risk and liability associated with treatment.  I understand and expressly agree ZMT undertakes no duty or liability in regard to the voluntary treatment provided to me. 

I hereby consent to the performance of routine evaluation and massage therapy, or other related services for the above-named Client, including various massage therapy techniques, including without limitation, Swedish massage, sport massage, cupping, graston technique, deep tissue, and/or the like, as considered applicable or necessary in the judgment of the staff at ZMT.  I understand that unless otherwise stated, this consent shall remain in effect for the pendency of the relationship between ZMT and Client. 

I understand and expressly agree that ZMT may make recommendations for supplements and other products that are available in the office and online, and that these are sold for-profit. I understand and acknowledge that supplements and other products may not be regulated by the FDA, and therefore the use of any suggested supplement or product can pose certain actual or potential risks, including serious physical injury and/or death. I understand that I am not obligated to purchase these products from ZMT, and that should I choose to purchase the suggested supplements or products, I may purchase these products from any source that I choose. I understand that if I choose to purchase any supplements from ZMT, all sales are final, and they may not be returned for exchange or refund for any reason.

Moreover, unless Client expressly informs ZMT otherwise, Client acknowledges, accepts, and agrees that ZMT may take photographs, videos, and/or recordings (the “Recordings”) of various aspects of the Client involved in treatment and/or massage therapy services, whether for educational, research, and/or promotional purposes.   In conjunction with such Recordings, I hereby assign to ZMT all worldwide rights, title, goodwill, moral rights, and interest, in perpetuity, to use the Recordings in whatever form, format, device, platform, media or medium now known or hereafter developed, and by whatever means transmitted or made available that ZMT may choose.  Further, I, the undersigned, waive any right to inspect or approve any finished product of the Recordings.  I also waive any and all rights to any direct and/or residual monies which may be derived from the use thereof by or on behalf of ZMT.

I acknowledge that I have had the full opportunity to read and consider the contents of this Consent Form. I understand that by signing this Consent Form, I am giving consent to the use and disclosure of my protected health information to carry out treatment, payment activities, promotional activities, and massage therapy operations.

I have read, understand, and agree to the foregoing. The waivers and releases contained herein are made by the undersigned on behalf of the undersigned individually, and on behalf of the undersigned's heirs, agents, next of kin, assigns, and/or the like.  The undersigned affirms that he or she is authorized to execute this Release on behalf of all such persons.

We will require all clients to keep an active credit card on file with us before scheduling an

appointment.

Cards on File will be used for:

•Payment for Treatment – When you come in for a visit, you will have the option of using the card on

file or you may present a different method of payment at that time for the services rendered. Payment is expected

and required, in full at the time of services.

•Outstanding Balances – If for any reason your account has a previous outstanding balance, your card on

file may be used to settle that outstanding balance.

•Missed or canceled appointments - Please refer to our cancellation policy regarding specific appointments and their cancellation notice requirements/fees.

If you have any questions, please do not hesitate to ask, as our staff is happy to speak with you about your account at any

time.

Please call our office at (INSERT NUMBER) during normal business hours or email us at (INSERT EMAIL). This in no way will compromise your ability to dispute a charge.

By agreeing above, I understand and expressly agree that I hereby authorize ZMT, LLC to charge the full outstanding amount of any balance die to the credit card provided below. In the event that the below referenced credit card can no longer incur and/or otherwise accept any charges, I agree that I will immediately provide ZMT, LLC with alternative credit card information which I then grant and authorize ZMT, LLC the right and ability to charge in an effort to satisfy the full outstanding amount of any balance due and owing upon my account. I understanding that upon booking / scheduling services, that if I do not act in accordance with ZMT, LLC’s Cancellation Policy, that I have an obligation to pay the cancellation and/or no show fee. I further understand that I also have an absolute obligation to pay for all authorized services performed and costs incurred by ZMT, LLC on my behalf. I expressly understand and agree that should I fail to

pay all amounts owed in a timely manner, per the terms of this authorization, my credit card(s) will be charged in an amount equal to the full outstanding balance plus any interest that has accrued. By providing such information, I represent that I am authorized to incur charges for fees against the payment card provided below.

Moreover, I have read and understood the foregoing, and no other or different statement(s) have been made to induce me to sign this Agreement.  I understand that even if such statements have been made, they are superseded by this document.  I am voluntarily signing this release with full awareness that by doing so, I am giving up valuable legal rights.   I have been given an adequate opportunity to review and ask any questions related to this document and voluntarily consent to all provisions contained herein.

WAIVER AND RELEASE OF LIABILITY

IN CONSIDERATION OF the risk of injury that exists while participating in (hereinafter the "Activity"); and

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

I HEREBY, for myself, my heirs, executors, administrators, assigns, or personal representatives (hereinafter collectively, "Releasor," "I" or "me", which terms shall also include Releasor's parents or guardian if Releasor is under 18 years of age), knowingly and voluntarily enter into this WAIVER AND RELEASE OF LIABILITY and hereby 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 , located at , , , their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns (collectively "Releasees"), from any physical or psychological injury that I may suffer as a direct result of my participation in the 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 PARTICIPATING IN THIS ACTIVITY, WHICH MAY INCLUDE, BUT ARE NOT LIMITED TO: PHYSICAL OR PSYCHOLOGICAL INJURY, PAIN, SUFFERING, ILLNESS, DISFIGUREMENT, TEMPORARY OR PERMANENT DISABILITY (INCLUDING PARALYSIS), ECONOMIC OR EMOTIONAL LOSS, AND DEATH. I UNDERSTAND THAT THESE INJURIES OR OUTCOMES MAY ARISE FROM MY OWN OR OTHERS' NEGLIGENCE, CONDITIONS RELATED TO TRAVEL TO AND FROM THE ACTIVITY, OR FROM CONDITIONS AT THE ACTIVITY LOCATION(S). NONETHELESS, I ASSUME ALL RELATED RISKS, BOTH KNOWN AND UNKNOWN TO ME, OF MY PARTICIPATION IN THIS ACTIVITY.

I FURTHER AGREE to indemnify, defend and hold harmless the Releasees against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs.

I FURTHER ACKNOWLEDGE that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize to provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs involved and agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

I FURTHER ACKNOWLEDGE that this Activity may involve a test of a person's physical and mental limits and may carry with it the potential for death, serious injury, and property loss. I agree not to participate in the Activity unless I am medically able and properly trained, and I agree to abide by the decision of the official or agent, regarding my approval to participate in the Activity.

I HEREBY ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS "WAIVER AND RELEASE" AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. I EXPRESSLY AGREE TO RELEASE AND DISCHARGE AND ALL OF ITS AFFILIATES, MANAGERS, MEMBERS, AGENTS, ATTORNEYS, STAFF, VOLUNTEERS, HEIRS, REPRESENTATIVES, PREDECESSORS, SUCCESSORS AND ASSIGNS, 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 FOR PERSONAL INJURY OR PROPERTY DAMAGE.

To the extent that statute or case law does not prohibit releases for ordinary negligence, this release is also for such negligence on the part of , its agents, and employees. I agree that this Release shall be governed for all purposes by law, without regard to any conflict of law principles. This Release supersedes any and all previous oral or written promises or other agreements. In the event that any damage to equipment or facilities occurs as a result of my or my family's or my agent's willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any such actions of neglect or recklessness.

THIS WAIVER AND RELEASE OF LIABILITY 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 of equal bargaining strength. Both Participant,  and agree that this agreement is clear and unambiguous as to its terms, and that no other evidence shall be used or admitted to alter or explain the terms of this agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into.

In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall remain in full force and effect. If a court should find that any provision of this agreement to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed and enforced as so limited.

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 RELEASE CANNOT BE MODIFIED ORALLY. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND THAT I AM SIGNING IT OF MY OWN FREE WILL.