Loading...

Allergy Center of Bend, LLC

Allergy Center of Bend, LLC, requires 48 hours notice for any canceled appointments. No shows or appointments canceled within 48 hours of scheduled time will be charged the full price of your session. To cancel or reschedule, please call us at 541-241-8782. We do not give refunds.

In scheduling this appointment I hereby release Allergy Center of Bend, LLC, Kristen Jividen, their agents, employees, successors and assigns, and their respective heirs, personal representative, affiliates, and any or all persons, liable or who might be claimed to be liable, whether or not here in named, none of whom admit any liability to the undersigned, but all expressly denying liability, for any, and all actions, causes of action, claims and demands of any and every kind and also any and all injuries and damages that may occur in the present or develop in the future.

I understand that I will be receiving an energy work session and that the purpose of the session is for the well being of my heart and mind. I understand that there is no implied or stated guarantee of success or effectiveness of individual technique or series of appointments. I hereby acknowledge that this is not a substitute for medical care, examination or diagnosis. We do not diagnose, give medical advice, make claim to cure, or predict the future. We reserve the right to refuse service to anyone.

Governing Law/Venue: This agreement shall be governed and construed in accordance with the laws of the State of Oregon. Any claim, action, or suit between Allergy Center of Bend, LLC, and Client that arises out of or relates to performance of this agreement shall be brought and conducted solely and exclusively within the Circuit Court for Deschutes County, Oregon. Provided, however, that if any such claim, action or suit may be brought only in a federal forum, it shall be brought and conducted solely and exclusively within the United States District Court of Oregon. Client, by execution of this agreement, hereby consents to the in personal jurisdiction of said courts.

I agree that neither I, my heirs, assigns or legal representatives will sue or make any other claims of any kind whatsoever against Allergy Center of Bend, LLC, or its members for any personal injury, property damage/loss, or wrongful death, whether caused by negligence or otherwise.

By signing below, I have read and agree to the terms above.

Today's Date: October 26, 2021

(You will receive an email reminder before your appointment)

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!