Disclaimer for Placental Encapsulation Services
I hereby certify and agree to the following:
I accept full responsibility for my health and voluntarily complete this Acknowledgment and Release of Liability. I certify that I am seeking Alma Madre's placental encapsulation service, which I understand is not medical diagnosis or treatment or a substitute for medical diagnosis or treatment. I certify that regarding any medical conditions or concerns I may have, I have been advised to consult with my personal care physician and understand that Alma Madre is a placenta encapsulation service, and is not a primary care medical institution.
I understand that placental encapsulation has not been registered or approved by the FDA or COFEPRIS and may not be offered by practicing physicians (allopathic or otherwise) and may be considered experimental. I understand and accept that neither Guadalupe Covas nor any member of Alma Madre S.C. make no representations, express or implied, regarding the effects or results of placental encapsulation tests and shall not be responsible for them.
I certify that I seek the advice and placenta encapsulation service of Alma Madre S.C. in a personal capacity only, and I do not represent any government agency, law firm, attorney, or investigator. I am not involved in a lawsuit nor am I collecting information for a potential lawsuit.
I understand and accept on behalf of myself, my dependents, heirs, administrators, legal representatives and assigns, to release and hold harmless Guadalupe Covas, Alma Madre SC, and each and every one of the associates, employees, agents and representatives of these , from any and all liability for illness, injury or death, and for any loss or damage related thereto, whichever may occur, in connection with my consultation and/or treatment and/or service by Guadalupe Covas, Alma Madre SC Without limitation, I understand and accept that neither Guadalupe Covas nor Alma Madre SC, nor any associate, employee, agent or representative thereof, is responsible for any damage, injury, death, loss, delay or damage direct, indirect, consequential or incidental. inconveniences of any kind that may be caused by any act or omission, including, without limitation, any intentional or negligent act, breach of an act or breach of contract.
My signature below indicates that I have carefully read and reviewed this Acknowledgment and Release of Liability, and fully understand all of its terms and conditions; I acknowledge and accept all risks and limitations involved in seeking advice, treatment therapies and placenta encapsulation services from Alma Madre S.C., and associates, employees, agents and representatives thereof; I have not relied on any other promise, agreement or representation by Guadalupe Covas, Alma Madre S.C. or any associate, employee, agent or representative thereof in connection with the treatment provided or the terms of this Acknowledgment and Disclaimer; Guadalupe Covas, Alma Madre S.C. has encouraged me to seek the advice of an attorney regarding this Acknowledgment and Release of Liability; and I execute and deliver this Acknowledgment and Release of Liability freely and voluntarily and without action or duress, and with full knowledge of the representations contained herein and the rights assigned, surrendered, released and discharged.
