Complementary Therapy Consent Form Name First Last Type of therapy/service (Please list below) - May include: Reiki, Yoga, Meditation, etc...* Example: Reiki, Yoga, Meditation, etc...I would like to be informed of upcoming complementary therapy programs available* Yes No My preferred method of communication: E-Mail Phone E-mail Address:* Phone Number*Emergency Contact Name* First Last Two emergency contacts required Phone Number*Alternate Phone NumberEmergency Contact Name* First Last Two emergency contacts requiredPhone Number*Alternate Phone NumberConsent* I agree and understand the below terms and conditionsI have been informed of the nature of the therapy I am receiving and understand that complementary therapy is a non-invasive therapy designed to promote comfort, relaxation, overall health and well-being. I am aware that complementary therapy is not a medical treatment and is not a substitute for professional medical advice, treatment or intervention. I understand that Hospice Vaughan is not responsible for any injuries that may occur during my treatment and I agree to hold Hospice Vaughan entirely free from any liability. I acknowledge any risks involved with my selected therapy, and do not have any conditions that would increase my risk of injury. I understand that complementary therapy sessions will be administered by volunteers and/or employees of Hospice Vaughan trained in the provision of the above therapy and will be given only with my consent. I understand that I have the right to withdraw consent at any time or discontinue service. I have read and understand the above information and consent to receive the complementary therapy listed above. Photo Release I grant permission for any photos that may be taken at the event to be used without compensation in any hospice print or promotional materials such as but not limited to their website, annual report, and brochures (if applicable)
