Showplace Intake Survey
WE are excited for your visit to the Wellness Eternal Showplace! Please complete this intake survey at least 24 hours prior to your visit. If you have any questions please call us at 914-846-9444 or send us an email at [email protected]. WE look forward to guiding you to Generational Health!
Health Survey:
Please select all that apply...
I hereby acknowledge and agree to the following terms and conditions in consideration for being permitted to utilize the wellness solutions offered by Wellness Eternal LLC's Showplace located at 401 Columbus Avenue, Suite 203, Valhalla, NY 10595:
Release of Liability Waiver for Wellness Solutions:
Acknowledgment of Risks: I understand and acknowledge that the wellness solutions provided by Wellness Eternal LLC's Showplace, including but not limited to diagnostics, hyperbaric therapy, red light therapy, infrared sauna, PEMF (Pulsed Electromagnetic Field) therapy, EMF (Electromagnetic Field) protection, grounding therapy, nanoparticles therapy, supplements, vibration therapy, pulse light therapy, sound therapy, breath-work, meditation, nutrition / culinary medicine guidance, hot and cold therapy, aromatherapy, aesthetics solutions, compression therapy, virtual reality therapy, and any other wellness solutions offered, are intended for general wellness purposes only.
Certification of Age and Medical Conditions: I certify that I am over the age of 18 and do not have any implanted medical devices such as insulin pumps, defibrillators, pacemakers, or any other similar devices. Further, I certify that I do not have any medical conditions including but not limited to cancer, epilepsy, infections, chronic diseases, pregnancy, or any other contraindications that may be affected or exacerbated by the utilization of the wellness solutions provided by Wellness Eternal LLC's Showplace.
Acknowledgment of Inherent Risks: I acknowledge that the utilization of wellness solutions involves inherent risks, including but not limited to the risk of physical injury, allergic reactions, or other adverse effects.
Disclaimer of Professional Medical Advice: I understand that Wellness Eternal LLC, its partners, and employees are not medical professionals and that the wellness solutions provided are not a substitute for professional medical advice, diagnosis, or treatment.
Release of Liability: In consideration for being permitted to use the wellness solutions provided, I hereby release, waive, discharge, and covenant not to sue Wellness Eternal LLC, its officers, directors, employees, agents, partners, affiliates, successors, and assigns (collectively referred to as "Released Parties") from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me or to any property belonging to me, whether caused by the negligence of the Released Parties or otherwise, while utilizing the wellness solutions provided by Wellness Eternal LLC's Showplace.
Indemnification: I agree to indemnify, defend, and hold harmless the Released Parties from and against any and all liabilities, expenses, damages, and costs, including reasonable attorney's fees, arising out of or related to my use of the wellness solutions provided by Wellness Eternal LLC's Showplace.
Understanding of Terms: I acknowledge that I have carefully read this liability waiver and fully understand its contents. I voluntarily agree to be bound by its terms and conditions.
By digitally signing and submitting this form, I acknowledge that I have read and understand this liability waiver and voluntarily agree to its terms.
Informed Consent for Specific Wellness Solutions:
Far Infrared Sauna: I have read and understand the Release of Liability Waiver specific to the Far Infrared Sauna provided by Wellness Eternal LLC's Showplace.
Roxiva RX1 Safety Questionnaire: I have carefully read and completed the safety questionnaire for the Roxiva RX1 lamp, and I understand the risks associated with its use. I confirm that I have answered truthfully and understand the potential risks involved.
PEMF/Centropix/Kloud: I acknowledge that none of the statements in Centropix marketing and educational materials have been evaluated by the FDA, and I release Centropix USA from any claims arising from my use of their products.
BrainTap: I agree to indemnify BrainTap and hold them harmless from any claims arising from my use of their services. I acknowledge the disclaimer of warranties and limitation of liability outlined by BrainTap.
PLEASE READ THE WARNINGS BELOW CAREFULLY BEFORE USING THE VIRTUAL REALITY (VR) HEADSET.
To reduce the risk of injury or discomfort you should always follow these instructions and observe these precautions while using the VR headset:
It is important to remain seated while using the headset unless your content experience specifically requires standing.
Do not use the headset when you are tired, need sleep, under emotional stress or anxiety, or suffering from cold, flu, headaches, migraines, or earaches, as this can increase your susceptibility to adverse symptoms.
Use only in a safe environment: The headset produces an immersive virtual reality experience that distracts you from and completely blocks your view of your actual surroundings.
Always be aware of your surroundings before beginning use and while using the headset. Use caution to avoid injury and remain seated unless your content experience requires standing.
Use of the headset may cause loss of balance.
Remember that the objects you see in the virtual environment do not exist in the real environment, so don’t sit or stand on them or use them for support.
Serious injuries can occur from tripping, running into or striking walls, furniture or other objects, so clear an area for safe use before using the headset.
Take special care to ensure that you are not near other people, objects, stairs, balconies, open doorways, windows, furniture, open flames, ceiling fans or light fixtures or other items that you can bump into or knock down when using—or immediately after using—the headset.
Remove any tripping hazards from the area before using the headset.
Remember that while using the headset you may be unaware that people may enter your immediate area.
Do not handle sharp or otherwise dangerous objects while using the headset.
Never wear the headset in situations that require attention, such as walking, bicycling, or driving.
Make sure the headset is level and secured comfortably on your head, and that you see a single, clear image.
Make sure any headphone cables if used are not tripping hazards.
Ease into the use of the headset to allow your body to adjust; use for only a few minutes at a time at first, and only increase the amount of time using the headset gradually as you grow accustomed to virtual reality. Looking around when first entering virtual reality can help you adjust to any small differences between your real-world movements and the resulting virtual reality experience.
Take at least a 10 to 15-minute break every 30 minutes, even if you don’t think you need it. Each person is different, so take more frequent and longer breaks if you feel discomfort. You should decide what works best for you.
If using headphones, listening to sound at high volumes can cause irreparable damage to your hearing. Background noise, as well as continued exposure to high volume levels, can make sounds seem quieter than they actually are. Due to the immersive nature of the virtual reality experience, do not use the headset with the sound at a high volume so that you can maintain awareness of your surroundings and reduce the risk of hearing damage.
Do not use the headset while in a moving vehicle such as a car, bus, or train, as this can increase your susceptibility to adverse symptoms.
Discomfort:
Immediately discontinue using the headset if any of the following symptoms are experienced: seizures; loss of awareness; eye strain; eye or muscle twitching; involuntary movements; altered, blurred, or double vision or other visual abnormalities; dizziness; disorientation; impaired balance; impaired hand-eye coordination; excessive sweating; increased salivation; nausea; lightheadedness; discomfort or pain in the head or eyes; drowsiness; fatigue; or any symptoms similar to motion sickness.
Just as with the symptoms people can experience after they disembark a cruise ship, symptoms of virtual reality exposure can persist and become more apparent hours after use. These post-use symptoms can include the symptoms above, as well as excessive drowsiness and decreased ability to multi-task. These symptoms may put you at an increased risk of injury when engaging in normal activities in the real world.
Do not drive, operate machinery, or engage in other visually or physically demanding activities that have potentially serious consequences (i.e., activities in which experiencing any symptoms could lead to death, personal injury, or damage to property), or other activities that require unimpaired balance and hand-eye coordination (such as playing sports or riding a bicycle, etc.) until you have fully recovered from any symptoms.
Do not use the headset until all symptoms have completely subsided for several hours. Make sure you have properly configured the headset before resuming use.
Be mindful of the type of content that you were using prior to the onset of any symptoms because you may be more prone to symptoms based upon the content being used.
See a doctor if you have serious and/or persistent symptoms.
Seizures:
Some people (about 1 in 4000) may have severe dizziness, seizures, eye or muscle twitching or blackouts triggered by light flashes or patterns, and this may occur while they are watching TV, playing video games or experiencing virtual reality, even if they have never had a seizure or blackout before or have no history of seizures or epilepsy. Such seizures are more common in children and young people under the age of 20. Anyone who experiences any of these symptoms should discontinue use of the headset and see a doctor. Anyone who previously has had a seizure, loss of awareness, or other symptom linked to an epileptic condition should see a doctor before using the headset.
Contagious Conditions
To avoid transferring contagious conditions like conjunctivitis (pink eye), do not share the headset with persons with contagious conditions, infections or diseases, particularly of the eyes, skin or scalp. The headset should be cleaned between each use with skin-friendly non-alcoholic antibacterial wipes and with a dry microfiber cloth for the lenses.
Skin Irritation
The headset is worn next to your skin and scalp. Stop using the headset if you notice swelling, itchiness, skin irritation or other skin reactions. If symptoms persist, contact a doctor.
To reduce risk of electric shock:
Do not modify or open any of the components provided.
Do not use the product if any cable is damaged or any wires are exposed.
Damaged or Broken Device
Do not use the device if any part is broken or damaged.
Do not attempt to repair any part of the device yourself.
Avoid Direct sunlight on VR Headset lenses.
Direct sunlight on lenses may damage or degrade the VR Headset, including the optics and display. Do not store or carry the headset so the lenses are exposed to direct sunlight.
Supplements / Nutrition -
These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease. Our "Functions" and "Clinical Evidence" sections are based on scientific studies sourced from Pubmed, a trusted source, for informational purposes only and are not intended to be claims regarding our products.
VivoBase - EMF Protection
People who are really sick - may detox too quickly - use only home in only 1 per day, or plug in overnight - can cause herksheimer reaction.
Thetacoustics - REVibe - Vibroacoustic Chairs:
Contraindication - people with the follow should NOT use the ReVibe chairs:
Pacemakers-because there are magnets in the transducers
Recent surgery or open wound as VAT speeds up circulation and blood flow which aids in healing but if you have an open sore you want it to clot
Acute Inflammatory conditions
Hypotension
Deep Vein Thrombosis, DVT
Seizure Disorders
Caution with pregnancy
Specific frequencies are chosen to impact the area of concern for each client. For chronic conditions, the best long-term therapeutic benefits are often found in multiple sessions (up to 10 in some cases).
Anti-Aging Bed - MEDICAL DISCLAIMER: I acknowledge the medical disclaimer provided by the Anti-Aging Bed website and understand that the information provided is not intended to diagnose, treat, prevent, or cure any disease.
AMPCOIL
Thank you for your interest in AmpCoil, a wellness device from Health Evolution Technology, Inc. (HET). The AmpCoil includes all of its software and other components which make up the AmpCoil System including the AmpCoil PEMF Mat. The AmpCoil System generates a non-invasive pulsed electromagnetic field that emits a series of pulsing electromagnetic frequencies (PEMF).
Before your Demonstration please read and acknowledge each of the following statements:*
I am not pregnant or nursing.I do not have a pacemaker, magnetic chip implant, including an insulin regulator, or any other electronic implanted device, implanted stimulator or battery-operated electronic implant.I do not suffer from, or have been diagnosed with, Epilepsy or any other seizure-related disorder.I agree that if I have any metal implants, screws, plates, joints, metal IUD, or other metal in my body that may be affected by a strong electromagnetic field I will not place the coil directly on those areas.I agree that if I have multiple amalgam fillings that I will not place the coil directly on my head area.I agree that if I have body staples, such as gastric bypass, I will not place the coil directly over the staples and that I use the AmpCoil System at my own risk.All electronic devices (including cell phones) metal, watches, magnetic jewelry, credit cards, hearing aids, keyless entry and other electrically sensitive materials should be placed four feet away from the active coil.
Age - one choice must be selected to receive a demo:*
I am over the age of 18.I am under the age of 18 – my parent or legal guardian is filling out and signing this form on my behalf.
Photo/Video Release:
I hereby grant and authorize, Health Evolution Tech. Inc. (HET), dba AmpCoil, the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all picture(s) and/or video(s) taken of me, and/or testimonials I provide, to be used in and/or for promotional materials including, but not limited to newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalists, websites, social networking sites and other print and digital communications, without payment or any other consideration. This authorization extends to all languages, media, formats and markets now known or hereafter devised. This authorization shall continue indefinitely, unless otherwise revoked in writing.
The AmpCoil System is not a replacement for any medical treatment. The AmpCoil System is not intended for use in the diagnosis, treatment, cure, mitigation or prevention of any disease, medical condition, physical or psychological disorder. It should not be considered a replacement for medical advice or treatment. If you have a serious, acute, or chronic health concern, please consult with a healthcare professional.Thank you for your interest in AmpCoil! We may contact you for feedback about your Demo experience and provide additional information about the AmpCoil System.
WAIVER OF LIABILITY AND RELEASE AGREEMENT
I, wish to participate in the demonstration of the AmpCoil System offered by HET. As a precondition to participating in the Demonstration, I have read the following Release Agreement (the “Agreement”) and agree to its terms.
Assumption of Risk. I have been given the chance to ask questions concerning the Demonstration Disclosure Form, and all such questions have been answered to my satisfaction. Having read this form, I am fully aware of the precautions and warnings associated with the AmpCoil System, and hereby elect to voluntarily participate in the Demonstration. I voluntarily assume full responsibility for any risks of loss, property damage or personal injury which may be sustained by me as a result of participating in the Demonstration, unless caused by HET's sole, gross negligence.
Liability Release. I release HET, its successors, affiliates, partners, co-venturers and members, and the provider of this demonstration (), from any and all liabilities, claims, demands, actions, causes of actions, costs and expenses of any nature whatsoever arising out of any loss, damage, illness or injury, including death, that may be sustained by me or to any property belonging to me, arising from the Demonstration or while upon the premises where the Demonstration is being conducted, excepting those claims arising from HET's sole, gross negligence.
Indemnification. I agree to indemnify and hold harmless HET, its successors, affiliates, partners, co-venturers and members, and the provider of this demonstration (), from and against any loss, liability, damage or costs, including court costs and attorneys’ fees, HET may incur arising from my involvement in the Demonstration, excepting those claims arising from HET's sole, gross negligence.
Commitment to Local Laws and Protocols. I affirm any AmpCoil Demonstration shall be done in full compliance with all applicable public health guidelines which are or may be in effect at the applicable jurisdiction at the time of the Demonstration. I further affirm I will adhere to all applicable social distancing and cleanliness practices, and I have been given an opportunity to request any preferences I may have, in order to promote a safe experience for the demonstration.
The terms of this Agreement shall be severable, such that if any term is found to be unenforceable, the validity of the remaining portions shall not be affected thereby. In signing this Agreement, I acknowledge I have read both this Release Agreement form and the Demonstration Disclosure Form, understand it, and agree to be bound by its terms. I further acknowledge I sign this Release Agreement voluntarily and I am at least eighteen years of age.
[Please review and acknowledge the specific informed consent for each wellness solution provided by Wellness Eternal LLC's Showplace.]
I agree to digitally sign this waiver and that all of the information provided above is correct and I agree to Authorization for Release of Health Information Pursuant to HIPAA. By providing my phone number, I agree to receive text messages from the business.