Be Well BioSync (Intelligent Health Inquiry)

Medical History Disclosure

I understand that before participating in any service at Be Well Lifestyle Centers or its affiliates—including but not limited to chiropractic adjustments, massage therapy, IV/vitamin/peptide therapy, colon hydrotherapy, cupping, dry needling, compression therapy, vitamin injections, café services, and any other modality—I must fully disclose any and all medical treatments I've had in the past five (5) years that could directly or indirectly affect my safe participation. This includes, but is not limited to, any:

• Gastrointestinal evaluations or procedures
• Proctology diagnoses or treatments
• Scopes and scans with results other than normal findings
• Surgeries, medications, or diagnostic tests
• Chronic illnesses or conditions

Assumption of Risk

I acknowledge that certain services carry potential risks (e.g., perforation, injury, allergic reaction, discomfort). I accept full responsibility for understanding my own physical limitations and for stopping any procedure immediately if I experience pain, discomfort, or resistance.

Not a Substitute for Medical Care

I understand that practitioners at Be Well Lifestyle Centers and affiliates are not physicians; they do not diagnose, prescribe, or treat diseases. The services provided are supportive and complementary. It is always advisable to consult a licensed healthcare provider before undergoing any service.

Contraindications

I certify that I have not been diagnosed with any contraindications for the service(s) I'm consenting to receive. Should any such conditions arise or be disclosed later, I will inform the provider prior to treatment.

Liability Release

I hereby release Be Well Lifestyle Centers and its affiliates, along with their practitioners and staff, from any liability for harm, injury, or adverse events arising from the services I receive—provided that standard professional protocols are followed.

Marketing Communications Consent

By signing below, I consent to receive marketing communications from Be Well Lifestyle Centers via email and/or SMS (including updates, promotions, and wellness tips). I understand I may opt out at any time.

Acknowledgment

I fully understand that withholding relevant medical information may increase my risk of injury and/or limit the effectiveness of the services. I agree that this signed form will be placed in my permanent file, and that all disclosures herein are accurate to the best of my knowledge.