Immortal Flotation Waiver & Release Form

Gender: MaleFemale

ADDRESS INFORMATION

EMERGENCY CONTACT INFORMATION

HEALTH HISTORY

This basic health questionnaire will help insure the safety and well—being of our clients using the Float tank in Immortal Digital Life Cube.

Have you consulted with your doctor prior to making an appointment if you have any of the conditions below?

Please state any medical condition/treatment past or present not mentioned in this questionnaire you feel we should be aware:

In the past have you experienced any of the following?

*People with physical disabilities need to bring their own assistant. Please consult With the front desk staff prior to making an appointment.

I, the willing customer, will NOT use the float pool if: (please initial next to each line so we know that you understand)

SAFETY AGREEMENT

I hereby agree to irrevocably release and waive any claims that l have now or may have
hereafter against Immortal Digital life Cube and its employees and agents. I have read and fully
understand and agree to the above terms of this Liability Waiver Agreement. I am signing this agreement voluntarily and recognize that my signature servers as complete and unconditional release of all liability to the greatest extent allowed by law in the state of California.

"I have read in Its entirety and fully understand this Flotation Meditation Waiver"

HIPAA NOTICE OF PRIVACY PRACTICE

This notice of Private Practices describes how ADCMC may use and disclose my protected health information (PHl) only for each of the following purposes: treatment, payment and health care operations.

Treatment means providing, coordinating or managing health care and related services by one or more.
health care providers. Payment means such activities as obtaining reimbursement for services,confirming coverage and billing activities. Health care operations include the business aspects of running our practice. such as conducting quality assessment. employee review activities. licensing. auditing or arranging for other business activities.

I have the following rights with respect to my PHI. which I can exercise by presenting a written request to the privacy officer. These rights include:
-To request restrictions on certain use and disclosures of PHI. To inspect and copy PHl.
-To amend my PHl. To receive an accounting of disclosures of PHI. To obtain a paper copy of this notice from ADCMC upon request.

ADCMC required by law to maintain the privacy of, and provide individuals with, this notice of the legal duties and privacy practices with respect to PHI.

Signature below is only an acknowledgment that l have received this notice of ADCMC privacy practices.