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Acoustic Flow Chair (Session Release and Liability Waiver Form)

 

“The Activity” or “Services” or “Treatment” provided by the VibraSound Sensorium LSV IIC and LSV III (referred to as the “Acoustic Flow Chair”) incorporates light, sound, color, aroma, and vibration to create a state of mind called "Sensory Resonance" (collectively, the “Activity”). This relaxed state of mind is thought to encourage freedom of thought, expand awareness, improve creativity, and provide a safe alternative to addictive behavior through the stimulation of numerous brain centers. This technology is not approved of or disapproved of by any governmental or other regulatory agency.

WARNING: INDIVIDUALS WITH PHOTOSENSITIVE EPILEPSY OR OTHER NERVE CONDITIONS SENSITIVE TO FLICKERING LIGHT SHOULD NOT USE THE ACOUSTIC FLOW CHAIR 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 ACOUSTIC FLOW CHAIR. 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 ACOUSTIC FLOW CHAIR. IMMEDIATELY DISCONTINUE USE OF THE ACOUSTIC FLOW CHAIR IF YOU EXPERIENCE ANY OF THE FOLLOWING SYMPTOMS: INVOLUNTARY MOVEMENTS, DISORIENTATION, EYE OR MUSCLE TWITCHING, CONFUSION, DIZZINESS, CONVULSIONS OR NAUSEA. IN ADDITION, DO NOT USE THE ACOUSTIC FLOW CHAIR IF YOU HAVE AN IMPLANTED OR EXTERNAL ELECTRICAL MEDICAL DEVICE.

In exchange for participation in the Activity, the undersigned agrees as follows:

  1. I am over 18 years of age and am not under the influence of alcohol or drugs.
  2. I and anyone claiming on my behalf release and forever discharge Dr. Adam Rizvi, Dr. Monique Rizvi, and Dr. Nadia Rizvi, with Rizvi Medical Corporation doing business as Rizvi Brain Institute (“RBI”), InnerSense, Inc. (“InnerSense”), Reality Management Technologies (“RMT”), and The Reality Center (“TRC”) and each of their affiliates, successors and assigns, officers, employees, representatives, partners, agents, and anyone claiming through them (collectively, the “Released Parties”), in their individual and/or corporate capacities from causes of action of any nature and kind, known or unknown, which I may have arising out of or relating to any injury, loss or damage to person and property that may be sustained as a result of participation in the Activity (“Claims”).
  3. I understand that participation in the Activity involves inherent risks, including the risk of seizure, epilepsy, pain, suffering, illness, discomfort, involuntary movements, disorientation, eye or muscle twitching, confusion, dizziness, convulsions or nausea. I fully acknowledge and take full responsibility for all the risks involved with participating in the Activity and I assume any risk in such participation. Any actions or lack of actions taken on my part of such participation is done solely by choice, and any harm, injury or loss that may occur to me or my property as a result of my participation in the Activity, are neither the responsibility nor liability of the Released Parties. In the event that I am injured or harmed, I agree to assume any financial obligation, either through my personal health insurance or through other means, for any medical costs that may incur, and the Released Parties assume no responsibility for any medical expenses, injury, or damage suffered by me in connection with my participation in the Activity.
  4. I understand that it is my responsibility to consult with my primary care physician prior to participation in the Activity. I attest that I have undergone an evaluation with my primary care physician, or I certify that I am in good health physically, mentally, psychologically, and emotionally, and I fully understand and acknowledge that if I am not in good health, I am not permitted to partake in the Activity. I understand that the Activity is not advised for persons with a history of health conditions, including but not limited to: individuals with photosensitive epilepsy or other nerve conditions; individuals sensitive to flickering light because seizures may occur; individuals who have a personal or family history of epilepsy; individuals uncomfortable with bright light; individuals with any serious eye conditions; individuals under the restrictive care of a physician as a result of pregnancy; individuals with a family history of aneurysms; individuals who suffer from vertigo or dizziness; and individuals who have a heart condition or are under the restrictive care of a physician for any serious medical condition.
  5. I understand that participation in the Activity is not a substitute for professional care from a qualified medical professional.
  6. I understand that the Activity is provided on an “as is” and “as available” basis without warranties of any kind, either express or implied, including but not limited to the implied warranty of merchantability or fitness for a particular purpose.
  7. I accept full responsibility and waive all rights to liability or any claims against the Released Parties. I, on behalf of myself, my heirs, personal representatives, or assigns hereby forever release, waive, discharge, and covenant not to sue the Released Parties, for any injury, harm or other claim caused by either negligence or other acts or omissions (the “Release”). I understand and agree that this Release extends to and includes any and all damages, injuries, and claims which I do not anticipate or know to exist and to any and all damages, injuries, or claims which may develop in the future, and I hereby expressly waive and relinquish any and all rights under any law or statute to the contrary.
  8. By signing up for the Activity, I acknowledge that if I am injured or harmed, or if my property is damaged, during my participation in the Activity, I will be found by a court of law to have waived all rights to maintain suit against the Released Parties. I acknowledge, understand, and agree that this Release, and all of the terms and conditions contained herein, shall apply with equal force and govern any future Activity in which I partake with the Released Parties, thus obviating the need for me to sign this Release each and every time I partake in such Activity. I understand that I have given up substantial rights by signing this Release and am signing it freely and voluntarily without any inducement. If any portion of this Release is found unenforceable, illegal, or contrary to public policy by a court of competent jurisdiction, I agree that this Release shall remain in full force and effect except for such provision or part of any such provision held to be unenforceable.
  9. This Release constitutes the entire agreement between the parties and supersedes any prior oral or written agreements or understandings between the parties concerning the subject matter of this Release. This Release may not be altered, amended or modified, except by a written document signed by both parties. The terms of this Release shall be governed by and construed in accordance with the laws of the applicable state.
  10. HAVE YOU HAD OR DO YOU PRESENTLY HAVE ANY OF THE FOLLOWING CONDITIONS?

If your answer is "Yes" to one or more of the questions, the Released Parties kindly ask that you consult your physician before participation in the Activity.

  •  Do you have any cardiovascular disease, cardiac pacemaker, or heart disorder (including heart attack, high blood pressure, and angina)?
  •  Do you have any serious eye disorders (including glaucoma or retinal detachment)?
  •  Are you currently, or have you been during the past year, under the care of a physician for any serious mental or physical illness or neurological disorder?
  •  Are you under restrictive care due to pregnancy or in the first trimester of pregnancy?
  •  Have you ever suffered any serious injury, such as a concussion, to the head?
  •  Do you have any history of epilepsy or other nerve disorders making you sensitive to flashing lights?
  •  Do you have a family history of aneurysms?
  •  Do you suffer from frequent dizziness or vertigo?

Please let your physician know which questions you answered "Yes" to and have a conversation with them about what type of activity is suitable for your current condition.

By signing below, I hereby acknowledge that I have completely read and fully understand all of the provisions of this Release, and I am freely, knowingly, and voluntarily entering into this Release and agreeing to all terms herein.

Name (Print): _________________________

Address: _________________________ Street: ___________________

City: ____________________ State: ___________________ ZIP: ____________________

Date of Birth: _________________________

Signature: _________________________