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I verify that all information is correct and current to the best of my knowledge. I understand that any information provided is for safety purposes and will be kept strictly confidential.

I hereby give my consent to receive Love Light Healing Energy Work services and/or other treatment (“Services”) from Love Light Healing Center, and I acknowledge and agree that I am doing so at my own risk. My health and safety with respect to such Services are my sole responsibility. I acknowledge that my receipt of the Services from Love Light Healing Center, may result in the potential worsening of symptoms, Ab Reactions, or other loss, depending upon the illness or condition being treated, its natural course (which may include death if condition is progressive, aggressive or fatal), any detoxification process, resistance to healing or other factors. My decision to receive Services from Love Light Healing Center is voluntary, and I know of, understand and assume any and all the risks associated therewith.

In exchange for receiving Services from Love Light Healing Center, I, for myself and on behalf of my heirs, executors, administrators and personal representatives, hereby waive, release, discharge and hold harmless Love Light Healing Center, its members, officers, employees and agents from any and all liability for any and all injuries, including death, damages or claims relating to or resulting from my receipt of the Services, now or in the future, foreseen or unforeseen. Further, I will indemnify and hold Love Light Healing Center, its members, officers, agents and employees, harmless from and against any and all claims, rights, damages, liabilities, losses, costs and expenses (including reasonable attorneys’ fees) arising from or in connection with any injuries to other persons or damage to property caused by or attributed to me.

I acknowledge that I have read, and understand, the release and indemnification provisions set forth in the preceding paragraph, and agree to such terms.