intake-form | Shrum Health

Client Details

Business: Shrum Health and Wellness

Address: 514 E. Briggs Dr, Macon, MO 63552

Website: ShrumHealthAndWellness.com

Email: haley@shrumhealthandwellness.com

Phone: 660-386-0306

First name*

Last name*

Email*

Phone*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

I, [Client Above], of [Address Above] in consideration of participating in any services offered by Shrum Health and Wellness (including but not limited to Yoga classes; Pulsed Electromagnetic Field (PEMF) therapy; Health Coaching; Infrared Sauna; Cold Plunge; Red Light Therapy; and any other wellness services, whether in-person at 514 E. Briggs Dr, Macon, MO, or online/virtually), hereby agree to the following terms. This agreement applies to all services I participate in now or in the future and remains in effect unless revoked in writing.

1. Description of Services

Shrum Health and Wellness offers wellness services designed to promote overall health, relaxation, and personal development. These include:

Yoga classes: Physical postures, breathing, and mindfulness for flexibility, strength, and stress relief.
PEMF Therapy: Electromagnetic fields to support cellular health and wellness.
Health Coaching: Apartnershiptohelpsetandachievepersonalgoalsinareas like health, work, and relationships (not medical treatment or therapy).
Infrared Sauna: Heat therapy for detoxification, relaxation, and pain relief.
Cold Plunge: Cold water immersion for recovery, circulation, and mental resilience.
Red Light Therapy: Light-based treatment for skin health, inflammation reduction, and recovery.

All services are for general wellness and are not substitutes for medical care.

2. Assumption of Risk

I understand that all services involve inherent risks, and I voluntarily assume them. Risks may include:

Physical injury (e.g., strains, sprains, falls, muscle soreness from yoga or PEMF).
Discomfort or adverse reactions (e.g., nausea, headache, fatigue from PEMF, sauna, or cold plunge).
Temperature-related issues(e.g., overheating/dehydration from sauna; hypothermia/shock from cold plunge).
Skin or eye irritation (e.g., from red light therapy if eyes are unprotected).
Emotional or mental stress (e.g., during coaching discussions).
Equipment or facility-related issues(e.g., slips on wet surfaces near cold plunge; malfunction of devices).

I agree to use services at my own risk, follow all instructions, and stop if I feel unwell.

3. Release of Liability

I hereby release, waive, discharge, and agree not to sue Shrum Health and Wellness, its owners, instructors, employees, or affiliates (collectively, “Released Parties”) from any and all liability, claims, demands, or causes of action arising from my participation in any services, including injury, loss, damage, or death, whether caused by negligence or otherwise, to the fullest extent permitted by law.

4. Informed Consent and Medical Disclaimer

I acknowledge that these services are for wellness only and are not medical advice, diagnosis, treatment, therapy, or substitutes for professional healthcare. For health coaching, I understand it is a collaborative process where I am responsible for my own decisions, actions, and results—no guarantees are made.

I have consulted a physician or healthcare provider before participating and confirm I am physically and mentally capable.
I will inform Shrum Health and Wellness of any changes in my health.
If under medical care (e.g., for mental health), I will notify my provider about these services.

Medical Disclosure (Check and Specify):

Do you have any medical conditions, injuries, implants, or limitations?*

Yes

Are you pregnant or recently postpartum?*

Yes

Do you have implanted devices (e.g., pacemaker, defibrillator, insulin pump)? *

Yes

Have you consulted a physician about participating in these services?*

Yes

Have you been cleared for these services by a healthcare provider? *

Yes

Healthcare Provider Information (Optional):

Health Provider's Name:

Health Provider's Phone

Contraindications (Do NOT Participate If Any Apply—Consult a Doctor First):

Pregnancy (all services; especially sauna, cold plunge, PEMF, red light).
Implanted electronic/magnetic devices (e.g., pacemaker, defibrillator, cochlear implant for PEMF, sauna, red light).
Cardiovascular issues(e.g., heart disease, high/low blood pressure, recent heart attack for sauna, cold plunge, PEMF).
Active bleeding, hemorrhaging, blood clots, or heavy menstruation (PEMF, cold plunge, sauna).
Epilepsy, photosensitivity, or sensitivity to light/heat/cold (red light, sauna, cold plunge).
Acute injuries, infections, fever, or insensitivity to heat/cold (all services).
Chronic conditions impairing sweating or temperature regulation (e.g., MS, diabetes with neuropathy for sauna).
Alcohol/drug use or certain medications (e.g., diuretics, beta-blockers affecting heat tolerance for all).
Under 18 without guardian consent (all services).

If unsure, consult a physician. Remove all metal, electronics, jewelry, and magnetic items before sessions.

Instructions for Safe Use:

Hydrate before, during, and after (especially sauna, cold plunge, PEMF).
Follow session limits(e.g., 15–40 min sauna; up to 6 min cold plunge; 10–20 min red light).
Start slowly; notify staff of discomfort.
For coaching: Communicate honestly; sessions are hybrid (in-person/Zoom); contact via email/phone between sessions.
For all: No unsupervised use; comply with rules.

5. Indemnification

I agree to indemnify and hold harmless the Released Parties from any claims, damages, or expenses (including legal fees) arising from my participation or breach of this agreement.

6. Photo/Video Release (Optional)

I ( ) consent ( ) do not consent to Shrum Health and Wellness using photos/videos of me during services for promotional purposes (e.g., social media, website).

7. Coach-Client Relationship (For Health Coaching)

This is an alliance, not therapy or medical care. I am responsible for my wellbeing and outcomes.
Confidentiality: Information shared is confidential unless required by law (e.g., imminent harm) or already public.
Ethics: Coachfollowsrelevantstandards;servicesarenotmedicaldespiteCoach’s nursing background.
Sessions: Mutually scheduled; late arrivals shorten time; email/phone support between as needed.

8. Cancellation Policy

I agree to provide 24 hours’ notice to cancel or reschedule any session. Late cancellations (less than 24 hours) incur a 50% service fee; no-shows or arrivals more than 10 minutes late incur a 100% fee. Late arrivals (within 10 minutes) receive a shortened session at full price. Exceptions may be made for emergencies if Shrum Health and Wellness is contacted promptly.

9. Additional Terms

This agreement is governed by Missouri law and is the entire understanding between us.
If any part is invalid, the rest remains enforceable.
I am at least 18 (or guardian signs below) and enter this willingly.

I have reviewed the contract and agree to the terms

Yes

Client Signature*

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Client Name*

Are you 18 or Older?*

Yes