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Liability Waiver

Scope of practice: Quantum therapy is not a replacement for any current or future medical treatments. QRS does not prescribe any medications or offer any medical advice to override any medical advice. QRS only offers an alternative to enhance current body functionality, and results will vary dependent upon the induvial and their lifestyle.

Modesty: QRS recommends that the individual wear very light clothing in a minimal amount or the individual does have the option of not wearing clothing. We offer a changing station for privacy located beside the pod to accommodate each individual. 

Intoxicants and medications: If the individual appears to be under any influence of alcohol or medications that would impair the individual, QSR will not allow the session to happen and will charge a cancellation fee.

Privacy: Any information shared during the sessions strictly confidential. We will not share any of this information without your written consent or legal subpoena.

Hygiene: proper hygiene and cleanliness is expected by each individual.

Cancellations and rescheduling: Cancellations must be made at least 24 hours prior to the appointment or the individual will be charged a cancellation fee of $50.00. There will not be any fee to reschedule an appointment to another time if that is completed prior to the 24-hour deadline.

Lateness: Please arrive 5 minutes early to get all paperwork processed on time before your individual session.

First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
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.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
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.


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