Please read the content below then scroll to the bottom of the form to sign

Client Information

CLIENT CONTACT and GENERAL INFORMATION

Date:
Client Name:
Name You Go By:
Address:
Primary #: Mobile Home
Email: Please list the email you want to use for billing statements.
If Employed, who is your Employer:		Work Phone #:
Date of Birth:	Age:
Gender Assigned at Birth:

EMERGENCY CONTACT INFORMATION:

In case of emergency notify:

*Name:
*Relationship:
*Phone:

If you were referred to us, who can we thank?

BILLING INFORMATION:

Please select the payment coverage you expect to use (Self-Pay, Health Insurance, Auto Insurance PIP, L & I Insurance) and fill in the required information.

SELF-PAY
HEALTH INSURANCE
Health Insurance Company:
Health Insurance Member ID:
Group #:
Do you have a Co-Pay? YES NO If you answered YES, how much is the Co-Pay?
Is this an Employer Health Insurance Policy? YES NO

AUTO INSURANCE
Motor Vehicle Accident (first party only):
Claim #:	Date of Accident:
Claim Rep Name:	Claim Rep Phone #:

L & I INSURANCE (Your Claim must be open and active)
L & I Claim Insurance Company:
Claim #:	Date of Accident:
Claim Rep Name: (Required)	Claim Rep Phone #:(Required)

Financial Agreement and Policies

RESPONSIBILITY OF PAYMENT
I understand that I am ultimately responsible for payment for all Lake Washington Wellness services and products provided to the Client listed on this form. I understand if I am a parent or guardian registering a minor I am ultimately responsible for the payment of the charges incurred at Lake Washington Wellness.

ON FILE CREDIT CARD
I understand that Lake Washington Wellness requires that I have an active Credit Card on file for the purposes of holding appointments and for the payment of services, products, insurance co-pays, coinsurance, unreimbursed insurance claims, missed appointments and late cancel fees.

MISSED APPOINTMENTS, LATE CANCELLATION & LATE ARRIVAL POLICY

I understand that if I miss an appointment I am responsible for a $110.00 NO SHOW Fee which I authorize be charged to my on-file credit card.
I understand if I arrive 15 minutes late or later for an appointment, my appointment will be rescheduled due to insufficient time to treat and I am responsible for a $65.00 LATE CANCEL FEE which I authorize be charged to my on-file credit card.
I understand if I do not cancel my appointment 24-hours prior to my appointment date and time, regardless of the reason, I am responsible for a $65.00 LATE CANCEL FEE which I authorize be charged to my on-file credit card.

Please initial

APPROVAL OF OUTSTANDING BALANCES PAID USING ON-FILE CREDIT CARD
I understand that if I have an outstanding balance with Lake Washington Wellness, that Lake Washington Wellness will email statements to the email I have provided (if no email is provided, I understand the statement will be sent to the mailing address on file) and that any outstanding balance on the statement will be charged to my on-file credit card 15 days after the email (or mailing) sent date unless other arrangements have been made. I understand I am responsible for paying off my balance regardless of discrepancies and or disputes. I further understand if Lake Washington Wellness is unable to charge the on-file credit card, that my balance is due within 5 days. I understand unless payment arrangements have been made, delinquent accounts (45 days past initial billing date) will be referred to an independent collection agency or small claims court, in which case I will assume the full responsibility for collection costs, including any attorney and/or court fee.
Please initial

USE OF INSURANCE FOR PARTIAL OR FULL PAYMENT
I understand that if I use insurance for partial or full payment of services or products, that I am providing authorization for my insurance benefits to be paid directly to Lake Washington Wellness.

I understand that my insurance is an agreement between the insurance company and myself. I understand that Lake Washington Wellness will assist me in billing my insurance carrier. However, I am fully responsible for all payments that are due, this includes any copays, coinsurance, and payment in full for any claims that are unreimbursed due to deductibles and claim denial by the provided insurance carrier. I understand it is my responsibility to be aware of my insurance coverage and benefit information in or out of network. (To verify benefits and obtain any information regarding your insurance plan and coverage, contact your benefit plan carrier.)

I understand if I do not provide my insurance information and prescription prior to my appointment, Lake Washington Wellness cannot bill my insurance and I will be required to pay for the service at the time of service.

I understand that if I have not provided a prescription prior to my appointment thatI must pay for service at the time of serviceand I have a right to a refund provided I obtain a backdated prescription and submit it to Lake Washington Wellness within five calendar days of my visit.

As a Client of or guardian of a Client of Lake Washington Wellness I acknowledge that I am solely responsible for payment of all charges incurred while under treatment. I understand any unpaid balance not paid by the insurance company becomes my responsibility regardless of the in or out of network coverage.

I understand authorization for treatment may be required by my health insurance benefit plan. If I receive treatment without an authorization, or an authorization request is denied, I accept all financial responsibility for treatment provided. I understand maintenance of care may be considered medically necessary by my physician but is excluded from coverage on my insurance benefit plan. I understand if I am denied authorization, due to time and labor costs, Lake Washington Wellness does not assist in appeals and the appeal process is my responsibility.

I understand that Lake Washington Wellness does not accept third party claim information for motor vehicle accident claims. I understand that Lake Washington Wellness will not wait for settlement/payment on a third-party car accident claim. I understand Lake Washington Wellness will work with my lawyer/legal team in any aspects except financial arrangements and settlement. I understand if I provide third party information, I will be responsible for all costs during and after my treatment. I understand that any unpaid visits will be reported to a collection agency after 90 days if not paid regardless of a settlement pending.

OUT OF NETWORK INSURANCE BILLING
I understand that if I am choosing to have Lake Washington Wellness bill my insurance out of network that I am responsible for checking my coverage and benefit information. I understand that I as the patient I take full responsibility for any cost after the insurance processes or does not process the claim and pays or does not pay for services and products provided. I understand that all above financial agreement policies apply to me regardless of billing out of network.

CONSENT FOR RELEASE AND EXCHANGE OF INFORMATION
I give permission to Lake Washington Wellness to release information that is necessary for Lake Washington Wellness to receive payment for the services and products provided. I understand that this information may be conveyed verbally or in writing, and that said documentations or information may be transmitted in person or by the means of communication systems, such as fax machines, telephones, non- secure email, or through the postal system in a sealed envelope.

Date:
Client Name:
Phone:
Client or Parent/Legal Guardian Signature:

Clear

(draw your signature)

Massage Health Information

Date:
Client Name:
Primary Phone:

If you have been provided a prescription for the Massage Therapy,
please list the prescribing Physician/Chiropractor:

HEALTH INFORMATION

1. Areas of primary complaint:

*2. Have you received a massage before?
YES NO

If yes, when was the last time?

*3. Have you received massage before related to your primary complaint?
YES NO

*4. What is your preferred massage pressure?
Light    Light-Medium    Medium    Medium-Deep    Deep

5. If your visit is injury or health issue related, please explain how your symptoms started:

6. Date your symptoms/injury started (if applicable):
(If symptoms came on gradually please choose a date that symptoms prompted you to seek treatment.)

7. Prior to this onset, were you free of these symptoms?
Yes    No
Explain:

*8. Have you had any previous or current treatment for this problem?
Yes    No
If yes, what?

9. If you answered yes, to question 8, do you feel your previous treatment made it:
Better   Worse   Same

10a. What eases the pain?

10b. What aggravates the pain?

*11. Have you had an MRI related to this problem?
Yes No

Findings:

*12. Do you have any numbness/tingling?
Yes No
If yes, where?

13. On a Scale of 0-10, 1 being NO PAIN and 10 being WORST PAIN, what is the Level of Pain Intensity?

14. Select the Type of Pain

15. Pain Frequency: As a percent of time during the day select the Frequency of Pain

16. Please complete these sentences with a numerical %:

of the time, I am unable to Stand.

of the time, I am unable to Walk.

of the time, I am unable to Climb Stairs.

of the time, I am unable to Lift.

of the time, I am unable to Work.

of the time, I am unable to Wash, Dress, etc.

of the time, I am unable to Drive.

of the time, I am unable to Sit.

of the time, I am unable to Sleep.

If you are able to do everything listed above (fully functional), are you experiencing any pain related to these?

17. Please use the diagram below and use your mouse to circle or mark the areas of pain and discomfort.

Medication/Allergy information:

18. Please list all Medications/Supplements you are taking and why:

19. Please List Any Allergies (fragrance, lotion, food, etc.):

20. Are you Pregnant?
Yes No
If yes, due date:

*21. Are you experiencing headaches?
Yes No
Average # of Headaches per week:

Type of Headache:

22. Please list any surgeries, accidents or traumas:

PLEASE CHECK ANY OF THE CONDITIONS BELOW THAT APPLY:

MEDICAL HISTORY
Aids/HIV
Abrupt Weight Gain or Loss
Cancer
Diabetes
Excessive Hair Loss
Hepatitis A/B/C
Low Appetite
Osteoporosis
Pacemaker
Prostate
Seizures
Fibromyalgia

GASTROINTESTINAL
Acid Reflux
Bloating
Blood in Stool
Constipated
Heartburn or Acid Reflux
Hemorrhoids
Hernia
Indigestion
Loose Stools and/or Diarrhea
Nausea/ Vomiting
Stomach Pain
Ulcer (Diagnosed?)
Undigested Food in Stool

FAMILY HISTORY
Autoimmune
Cancer
Diabetes
Endocrine
Gallbladder
Heart
Kidney
Liver
Respiratory

MUCSCLE and JOINT PAIN
Arthritis, Tendonitis, Bursitis
Joint Pain/Stiffness
Low Back Pain
Lymphatic/Edema Swollen
Muscle Issues
Sore or Weak Knees
TMJ
Headaches
Osteopenia
Osteoporosis
Orthopedic Surgery

REPRODUCTIVE
Abdominal/Cramps
Breast Tenderness
Hot Flashes
Irregular Menstrual Cycle
Night Sweats
PMS
Birth

SKIN
Acne
Athletes Foot
Gallstones (history or current)
High pitched ringing in ears
Rash, Warts, Hives
Skin Rashes
Unable to adapt to stress

EMOTIONS AND SLEEP
Anger, Frustration, Irritable
Anxiety and/or Panic Attacks
Depression
Difficulty Concentrating
Frequent dreams
Insomnia
Mental Heaviness & Fogginess
Nervous/Restlessness
Over thinking, Worry
Poor Memory
Sadness, Melancholy
Snoring and/or Sleep Apnea

CARDIOVASCULAR
Blood Clots
Chest Pain
Cold Hands and Feet
Dizziness
High Blood Pressure
High Cholesterol
Irregular Heart Beat
Low Blood Pressure
Palpitations
VeinsCirculation
Poor Varicose
Pacemaker
Stroke
Heart Attack

RESPIRATORY
Asthma
Bleeding Gums
Cold Sores
Cough
Dry Mouth
Ear Pain
Frequent Colds
Ringing in Ears
Sinus Congestion
Shortness of Breath

NERVOUS SYSTEM
Seizures
Epilepsy
Multiple Sclerosis
ALS
Parkinsons
Sensory Loss/Change
Numbness/Tingling
Sciatica
Migraines/Headaches

HABITS AND USE

How often do you exercies per week?

How many alchoholic drinks do you have per day?

How many Cigarettes do you have per day?

Do you use recreational drugs?
Yes No

How many cups of coffee do you drink each day?

Additional info you would like your therapist to know about any of the boxes checked:

HEALTH RISK, INFORMATION DISCLOUSRE AND INFORMED CONSENT FOR IN-PERSON SERVICES

HEALTH RISKS OF IN-PERSON SERVICES
You understand that the wellness work (Massage, Acupuncture or other services) provided at Lake Washington Wellness involves close physical proximity over an extended period in a closed space, which can elevate the risk of disease transmission, including COVID-19.

You understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). You further understand that COVID-19 is extremely contagious and may be contracted from various sources. You understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

You understand that Lake Washington Wellness has implemented reasonable preventative measures and sanitation protocols intended to reduce the risk of disease transmission, including COVID-19.

You hereby acknowledge and assume the risk of becoming infected with COVID-19 or other public health risks through the treatments you receive at Lake Washington Wellness and you give your express permission to Lake Washington Wellness and the Licensed Staff at Lake Washington Wellness to proceed with providing care.

YOUR RESPONSIBILITY TO LIMIT YOUR EXPOSURE TO HEALTH RISKS
To obtain our health care services, you agree to take certain precautions which will help keep everyone safer from exposure to viruses and serious illness. If you do not follow the following safety standards, Lake Washington Wellness reserves the right to deny services.

1. You agree to cancel your in-person appointment if you have had symptoms of illness that are associated with contagious diseases such as the coronavirusand the fluin the past 72 hours.If you cancel for this reason, wewill not charge you our normal cancellation fee.

2. You agree to take your temperature before coming to each appointment. If your temperature is 100 Fahrenheit or moreyou agree to cancel the appointment. If you cancel for this reason, wewill not charge you our normal cancellation fee.

3. You agree to arrive no earlier than 5 minutes before your appointment.

4. You agree to wash your hands when you enter the building and before entering the clinic.

5. You agree to follow the safe distancing precautions we have set up in the waiting room and hallways.You will keep a distance of 6 feet (except while receiving treatment) and there will be no unnecessary physical contact (e.g. no shaking hands) with us or other visitors in our office.

6. You agree to wear a mask in all areas of the office. If you do not have a mask we will provide one.

7. If someone with whom you have contact tests positive for coronavirus or other highly infectious and life threating viruses, you agree to immediately let us know.

RIGHT TO REFUSE PROVIDING SERVICE
You understand that Lake Washington Wellness is committed to keeping you and all our Clients safe from the spread of disease. If you arrive for an appointment and the Staff at Lake Washington Wellness believes that you are exhibiting symptoms that could indicate the possibility of being infected with a transmissible disease or believe you have been exposed to a transmissible disease, like the coronavirus, you will be required to and you agree to leave the office immediately. Your appointment will reschedule as appropriate.

YOUR RESPONSIBILITY TO INFORM CLINIC AND THERAPIST OF PAIN, DISCOMFORT or CHANGE OF HEALTH
You understand that to provide the most effective treatment, you need to inform the Therapist of any pain or discomfort you are experiencing during this session. This includes informing the Therapist of any discomfort related to techniques or pressure being used. You also understand that if there is a change in your health between sessions, you will advise Lake Washington Wellness and the Therapist prior to your treatment.

CONSENT FOR RELEASE AND EXCHANGE OF INFORMATION
You understand that if Lake Washington Wellness is required by law to notify local health departments that you have been to our office you agree to allow Lake Washington Wellness to provide the information necessary to comply with the law. You give permission to Lake Washington Wellness to request or release information about your health care and any documentation of information concerning your carefor the purpose of case collaboration with the goal of advancing your health or insurance reimbursement.

INFORMED CONSENT
You understand that you are the decision maker for your health or the decision maker for minors health. This process is often referred to as “informed consent” and involves your understanding and agreement regarding the risks associated with the provision of health care including those associated with a pandemic like COVID-19.

You knowingly and willingly consent to the wellness treatment at Lake Washington Wellness with the full understanding and disclosure of the risks associated with receiving care during the COVID-19 pandemic.

You have read or have had this document read to you and you accept that it is not possible to consider every possible complication to care. You also agree that you have had the opportunity to contact Lake Washington Wellness with questions about this Informed Consent form and preventative measures and sanitation protocols.

AGREEMENT TO RECEIVE CARE
By signing below, you understand and agree to the contents of this Informed Consent document along with the current or future recommendation to receive care as is deemed appropriate for your circumstance or the circumstance of a Minor for whom you are the Parent or Guardian. You agree that this Informed Consent covers the entire course of care from all providers in at Lake Washington Wellness, Redmond, WA for your present condition and for any future condition(s) for which you seek care at Lake Washington Wellness, Redmond, WA.

This agreement is made in addition to any other general informed consent or business agreement that has been made between you and Lake Washington Wellness.

Client Name:

Primary Phone:

Date:

Client or Parent/Legal Guardian Signature:

Clear

(draw your signature)

LAKE WASHINGTON WELLNESS NOTICE OF PRIVACY

YOUR INFORMATION.

YOUR RIGHTS.
OUR RESPONSIBILITIES.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

YOUR RIGHTS

You have the right to:

Get an electronic or paper copy of your medical record
Correct your paper or electronic medical record
Request confidential communication
Ask us to limit the information we share
Get a list of those with whom we have shared your information
Get a copy of this privacy notice
Choose someone to act for you
File a complaint if you believe your privacy rights have been violated

YOUR CHOICES

You have choices in the way that we use and share information as we:

Tell family and friends about your condition
Provide disaster relief
Include you in a hospital directory
Provide mental health care
Market our services and sell your information
Raise funds

OUR USES AND DISCLOSURES

We may use and share your information as we:

Treat you
Run our organization
Bill for your services
Help with public health and safety issues
Do research
Comply with the law
Respond to organ and tissue donation requests
Work with a medical examiner or funeral director
Address workers’ compensation, law enforcement, and other government requests
Respond to lawsuits and legal actions

YOUR RIGHTS EXPLAINED

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

GET AN ELECTRONIC OR PAPER COPY OF YOUR MEDICAL RECORD

You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

ASK US TO CORRECT YOUR MEDICAL RECORD

You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
We may say “no” to your request, but we will tell you why in writing within 60 days.

REQUEST CONFIDENTIAL COMMUNICATIONS

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will say “yes” to all reasonable requests.

ASK US TO LIMIT WHAT WE USE OR SHARE

You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

GET A LIST OF THOSE WITH WHOM WE’VE SHARED INFORMATION

You can ask for a list (accounting) of the times we have shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

GET A COPY OF THIS PRIVACY NOTICE

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

CHOOSE SOMEONE TO ACT FOR YOU

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.

FILE A COMPLAINT IF YOU FEEL YOUR RIGHTS ARE VIOLATED

You can complain if you feel we have violated your rights by contacting us at our offices by phone or in-person.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/
privacy/hipaa/complaints/.
We will not retaliate against you for filing a complaint.

YOUR CHOICES

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

Share information with your family, close friends, or others involved in your care
Share information in a disaster relief situation
Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases, we never share your information unless you give us written permission:

Marketing purposes
Sale of your information
Most sharing of psychotherapy notes

In the case of fundraising:

We may contact you for fundraising efforts, but you can tell us not to contact you again.

OUR USES AND DISCLOSURES

How do we typically use or share your health information? We typically use or share your health information in the following ways.

TREAT YOU

We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you asks another doctor about your overall health condition.

RUN OUR ORGANIZATION

We can use and share your health information to run and improve our practice. Example: We use health information about you to manage your treatment and services.

BILL FOR YOUR SERVICES

We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay services for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We must meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

HELP WITH PUBLIC HEALTH AND SAFETY ISSUES

We can share health information about you for certain situations such as:

Preventing disease
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety

DO RESEARCH

We can use or share your information for health research.

COMPLY WITH THE LAW

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.

RESPOND TO ORGAN AND TISSUE DONATION REQUESTS

We can share health information about you with organ procurement organizations.

WORK WITH A MEDICAL EXAMINER OR FUNERAL DIRECTOR

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

ADDRESS WORKERS’ COMPENSATION, LAW ENFORCEMENT, AND OTHER GOVERNMENT REQUESTS

We can use or share health information about you:

For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services

RESPOND TO LAWSUITS AND LEGAL ACTIONS

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Client or Parent/Legal Guardian Signature Below:

Client Information:

First Name:	Last Name:	Birth Date:
Address:	City:	State:
Zip:	Email:	Phone:

Relationship to minor:

Full Name and Birth Date of family members under the age of 18

#1	First Name:	Last Name:	Birth Date:
#2	First Name:	Last Name:	Birth Date:
#3	First Name:	Last Name:	Birth Date:
#4	First Name:	Last Name:	Birth Date:
#5	First Name:	Last Name:	Birth Date:
#6	First Name:	Last Name:	Birth Date:
#7	First Name:	Last Name:	Birth Date:
#8	First Name:	Last Name:	Birth Date:
#9	First Name:	Last Name:	Birth Date:
#10	First Name:	Last Name:	Birth Date:

Put Your Legal Signature Below

Clear

Date and Time Signed:

By checking this box I confirm that the information provided is current and correct.

Send me emails about Account Management, Reminders, and Schedule Changes

Send a copy of this form to my email. Please be advised this will include personal health information.

PageRef:WK4

Our Privacy Policy

PLEASE NOTE THAT WAIVERKING, INC.’S (“WaiverKing”) PRIVACY POLICY HAS CHANGED EFFECTIVE May 25th, 2018.

You acknowledge that this privacy policy is a part of our website’s Terms of Service, and by accessing or using our website, you agree to be bound by all of its terms and conditions. IF YOU DO NOT AGREE TO THESE TERMS, AS UPDATED, PLEASE IMMEDIATELY STOP ACCESSING THE WEBSITE.

This document explains how we use your personal data.

When you sign up to use this service provider’s services, you do so through software provided by us, WaiverKing.

We are committed to ensuring the privacy of all users of our software and services and other visitors to our website. In this policy we explain how we hold, process and retain your personal data.

In respect to the account data, waiver data, and payment data (as defined below) that you provide to us, we are acting as a data processor on behalf of the service provider, who will be acting as the data controller in respect to such data. We will never store or control this data. You should direct any requests or queries you have regarding this data to the data controller, your service provider.

1. How we use your personal data

1.1. This section provides you with information about:

a) what personal data we hold and process;

b) in respect of personal data that we did not collect from you directly, where we obtained that data from, and what types of data we have collected;

c) the purposes for which we may process your personal data; and

d) the legal grounds on which we process your data.

Members and end users of our services

1.2. Account data. We may process information about you that you provide to us when you first sign up with a service provider ("account data"). This account data may include your name, address, telephone number, email address, date of birth, gender, employment details, and a photograph of you. We may use this data to create your account with the service provider when you sign up. This account data may be updated each time you complete a document through our software. We do not process your account data in any other way, or have access to it in any way.

The legal basis for this processing is our legitimate interests in providing our services to our clients, and ensuring that your account is updated each time that you complete a document through our software.

1.3. Waiver data. If you are using our software in order to sign documents such as a waiver, health form, contract, or questionnaire, we may process information that you put into such documents (“waiver data”). This waiver data may include your name, signature, date of birth, email address, information about your health and medical history, and any other information that you are required or requested to put into the document.

Once you have completed the document, we will process it, convert the document into a different format, and send it to your account with the service provider in order for it to be stored. We will never store your data permanently on our systems (although it may be stored in your account with your service provider).

The purpose for our processing your data in this way is to maintain and administer a complete and accurate record of the documents that you have signed and completed for your service provider. The legal basis for our processing your waiver data (to the extent that such waiver data does not class as a special category of personal data), will be our legitimate interests in providing our services to our clients who have asked you to complete the document in question, in order to ensure that a complete and accurate record of your signing and completing the documents is maintained and administered.

1.4. Sensitive Personal Data. During the course of using our software and services and providing us with information in order for us to provide our services to you, you may provide us with sensitive information about yourself (“sensitive data”). This sensitive data may include your health and medical history. We may use this data for providing our services to you. However, we will only process this sensitive data if you consent to us doing so.

[The consent to use this information needs to be provided by the parent for children under the age of 13. Anyone over the age of 13 can provide consent for use of their data under GDPR]

We comply with the requirements of the Children’s Online Privacy Protection Act. You must be at least 18 years old to have our permission to use the WaiverKing website. If you are between the ages of 13 and 17, or under the age of majority where you live, you represent that your legal guardian has reviewed and agreed to this privacy policy.

Other processing that we may carry out

1.5. Website data. We may process data about your use of our website and services ("website data"). The website data may include your IP address, geographical location, browser type and version, operating system, referral source, length of visit, page views and website navigation paths, as well as information about the timing, frequency and pattern of your service use. The source of the website data is our analytics tracking system. This website data may be processed for the purposes of analyzing the use of the website and services.

The legal basis for this processing is our legitimate interests, namely monitoring and improving our website and services.

We may also process this data for the purposes of diagnosing any issues we detect in relation to the use of our products or services. This data may be collected by our error-tracking software which is provided by Rollbar. We always try to ensure that any such data is anonymized so that you cannot be identified before it is stored in our records.

The legal basis for this processing is our legitimate interests in monitoring and improving our products and services.

1.6. Enquiry data. We may process information contained in any enquiry you submit to us regarding our products or services ("enquiry data"). The enquiry data may be processed for the purposes of offering, marketing and selling relevant products and/or services to you.

The legal basis for this processing is our legitimate interests, namely dealing with and responding to your enquiry appropriately.

1.7. Notification data. We may process information that you provide to us for the purpose of subscribing to our blog and press releases ("notification data"). The notification data may be processed for the purposes of sending you newsletters.

Where you are a corporate customer, the legal basis for this processing is our legitimate interests, namely the marketing of relevant products and services to you.

1.8. Correspondence data. We may process information contained in or relating to any communication that you send to us ("correspondence data"). The correspondence data may include the communication content and metadata associated with the communication. Our website will generate the metadata associated with communications made using the website contact forms. The correspondence data may be processed for the purposes of communicating with you and record-keeping.

The legal basis for this processing is our legitimate interests, namely the proper administration of our website and business and communications with users.

1.9. Payment data. We do not process payment information relating to goods and services that you purchase from the service provider. However, we do capture certain data relating to your payments and use them to update your account with the service provider ("payment data"). The payment data may include your contact details, your card details and the transaction details. The payment data may be processed for the purposes of updating your account with the service provider. The legal basis for this processing is our legitimate interests, namely our interest in the proper administration of our software and ensuring your account with the service provider is updated.

1.10. Other processing activities. In addition to the specific purposes for which we may process your personal data set out above, we may also process any of your personal data where such processing is necessary for compliance with a legal obligation to which we are subject, or in order to protect your vital interests or the vital interests of another natural person.

2. Providing your personal data to others

2.1. To our clients and partner service providers. The only third parties that we will disclose your personal data to are our clients (your service provider) who is the data controller in respect to the account data, waiver data, and payment data that we collect about you, and MINDBODY Inc. (“MINDBODY”), who provide software services to service providers in conjunction with the WaiverKing software. Your accounts are created by WaiverKing in the MINDBODY software on behalf of our clients.

2.2. Our insurers/professional advisers. We may disclose your personal data to our insurers, legal counsel, and/or professional advisers insofar as reasonably necessary for the purposes of obtaining and maintaining insurance coverage, managing risks, obtaining professional advice and managing legal disputes.

2.3. Where we provide your personal data to any third party. Where we share your personal data with any of the third parties referred to above, we will ensure this processing is protected by appropriate safeguards including a suitable data processing agreement with that third party.

2.4. To comply with legal obligations. In addition to the specific disclosures of personal data detailed above, we may also disclose your personal data where such disclosure is necessary for compliance with a legal obligation we have to comply with, or in order to protect your vital interests or the vital interests of another individual. This may include disclosing your personal data in response to lawful requests by public authorities, including to meet national security or law enforcement requirements.

2.5. We take reasonable and appropriate steps to ensure that third-party agents and service providers process your personal data in accordance with our Privacy Shield obligations and to stop and remediate any unauthorized processing. Under certain circumstances and pursuant to applicable laws, we may remain liable for the acts of our third-party agents or service providers who perform services on our behalf for their handling of your personal data that we transfer to them.

3. Transfers of your personal data outside of the European Economic Area

As further detailed below, we may transfer your personal data to our servers based in the US, as we are part of the Privacy Shield. Otherwise, where your personal data is transferred outside of the EEA, we will ensure that either (a) The European Commission has made an "adequacy decision" with respect to the data protection laws of the country to which it is transferred, or (b) we have entered into a suitable data processing agreement with the third party situated in that country to ensure the adequate protection of your data. In all cases, transfers outside of the EEA will be protected by appropriate safeguards.

4. Retaining and deleting personal data

4.1. Personal data that we process for any purpose or purposes shall not be kept for longer than is necessary for that purpose or those purposes. Details about members of our clients (your service provider) and end users of our services, including the account data, waiver data and sensitive personal data, will not be stored by WaiverKing.

4.2. Unless we contact you and obtain your consent for us to retain your personal data for a longer period, we will retain and delete your personal data as follows:

a) Website data will be retained for 12 months following the date of our last contact or dealing with you, at the end of which period it will be deleted from our systems.

b) Enquiry data will be retained for 12 months following the date of our last contact or dealing with you, at the end of which period it will be deleted from our systems.

c) Notification data (other than Notification data that is also Contact data) will be retained for 12 months following the date of our last contact or dealing with you, at the end of which period it will be deleted from our systems.

d) Correspondence data will be retained for 12 months following the date of our last contact or dealing with you, at the end of which period it will be deleted from our systems.

4.3. We may retain your personal data where such retention is advisory and/or necessary for compliance with a legal obligation to which we are subject (such as with regard to applicable statutes of limitations, litigation or regulatory investigations), or in order to protect your vital interests or the vital interests of another natural person.

5. Your rights

5.1. You may instruct us to provide you with any personal information we hold about you; provision of such information will be subject to:

a) your request not being found to be unfounded or excessive, in which case a charge may apply; and

b) the supply of appropriate evidence of your identity (for this purpose, we will usually accept a notarized photocopy of your driver’s license and/or passport and an original copy of a utility bill showing your current address).

5.2. We may withhold personal information that you request to the extent permitted by law.

5.3. You may instruct us at any time not to process your personal information for marketing purposes.

5.4. In practice, you will usually expressly agree in advance to our use of your personal information for marketing purposes, or we will provide you with an opportunity to opt out of the use of your personal information for marketing purposes.

5.5. Your right to access your data. You have the right to ask us to confirm whether or not we process your personal data and, to have access to the personal data, and any additional information. That additional information includes the purposes for which we process your data, the categories of personal data we hold and the recipients of that personal data. You may request a copy of your personal data. The first copy will be provided free of charge, but we may charge a reasonable fee for additional copies.

5.6. Your right to correct. If we hold any inaccurate personal data about you, you have the right to have these inaccuracies corrected. Where necessary for the purposes of the processing, you also have the right to have any incomplete personal data about you completed.

5.7. Your right to erasure. In certain circumstances you have the right to have personal data that we hold about you erased. This will be done without undue delay. These circumstances include the following: (1) it is no longer necessary for us to hold those personal data in relation to the purposes for which they were originally collected or otherwise processed; (2) you withdraw your consent to any processing which requires consent; (3) the processing is for direct marketing purposes; and/or (4) the personal data have been unlawfully processed. However, there are certain general exclusions of the right to erasure, including where processing is necessary: for exercising the right of freedom of expression and information; for compliance with a legal obligation; or for establishing, exercising or defending legal claims.

5.8. Your right to restrict processing. In certain circumstances you have the right for the processing of your personal data to be restricted. These circumstances include the following: (1) you do not think that the personal data we hold about you is accurate; (2) your data is being processed unlawfully, but you do not want your data to be erased; (3) it is no longer necessary for us to hold your personal data for the purposes of our processing, but you still require that personal data in relation to a legal claim; and/or (4)you have objected to processing, and are waiting for that objection to be verified. Where processing has been restricted for one of these reasons, we may continue to store your personal data. However, we will only process it for other reasons: with your consent; in relation to a legal claim; for the protection of the rights of another natural or legal person; or for reasons of important public interest.

5.9. Your right to object to processing. You can object to us processing your personal data where our legal basis for the processing is that it is necessary for: the performance of a task carried out in the public interest, or in the exercise of any official authority vested in us; or the purposes of our legitimate interests or those of a third party. If you make an objection, we will stop processing your personal information unless we are able to: demonstrate compelling legitimate grounds for the processing, and that these legitimate grounds override your interests, rights and freedoms; or the processing is in relation to a legal claim.

5.10. Your right to object to direct marketing. You can object to us processing your personal data for direct marketing purposes. If you make an objection, we will stop processing your personal data for this purpose.

5.11. Your right to data portability. Where you have given us consent to process your personal data, or where we are processing your personal data for the performance of a contract, you have a legal right to receive a copy of the personal data we hold about you in a structured, commonly used and computer readable format. When a data request is made of us we will make available all applicable personal data to you in a computer readable format and will transmit your personal data to the appropriate third party pursuant to your instruction. We will not process your data in this way if we believe that it may pose a threat to the security of the data.

5.12. Your right to object for statistical purposes. You can object to us processing your personal data for statistical purposes on grounds relating to your particular situation, unless the processing is necessary for performing a task carried out for reasons of public interest.

5.13. Automated data processing. To the extent that the legal basis we are relying on for processing your personal data is consent, and where the processing is automated, you are entitled to receive your personal data from us in a structured, commonly used and computer-readable format. However, you may not have this right if it would adversely affect the rights and freedoms of others.

5.14. Complaints to a supervisory authority pursuant to the GDPR. If you think that our processing of your personal data infringes data protection laws, you can lodge a complaint with a supervisory authority responsible for data protection. You may do this in the EU member state of your habitual residence, your place of work or the place of the alleged infringement. This provision is only applicable if you are subject to the protections of the GDPR.

5.15. Complaints if you are not subject to the protections of the GDPR. If you think that our processing of your personal data infringes data protection laws you may contact us via email at privacy@waiverking.com or mail at: WaiverKing, Inc. 340 S Lemon Ave # 2018 Walnut, California 91789.

5.16. Right to withdraw consent. To the extent that the legal basis we are relying on for processing your personal data is consent, you are entitled to withdraw that consent at any time. Withdrawal will not affect the lawfulness of processing before the withdrawal.

5.17. Exercising your rights. You may exercise any of your rights in relation to your personal data by written notice to us in addition to the other methods specified above.

5.18. Point of Contact Data. PARAGRAPHS 5.1 – 5.17 SHALL NOT APPLY TO ACCOUNT DATA, WAIVER DATA, OR PAYMENT DATA OBTAINED OR PROCESSED BY WAIVERKING. IN RESPECT OF SUCH DATA:

a) WAIVERKING IS ACTING AS A PROCESSOR OF THAT DATA AND THE MAIN CONTRACTOR IS THE CONTROLLER;

b) YOU SHOULD CONTACT THE SERVICE PROVIDER TO EXERCISE THE RIGHTS SET OUT IN THIS PARAGRAPH 5

6. Links To Other Websites. Except as otherwise discussed in this privacy policy, this document only addresses the use and disclosure of information we collect from you. Other websites accessible through our website have their own privacy policies and data collection, use, and disclosure practices. Please consult each website’s privacy policy. We are not responsible for the policies or practices of third parties, including any third-party site or other products and services used in connection with WaiverKing’s services. The inclusion of a link does not imply endorsement of the linked site or service by us or by our affiliates.

We are not responsible for the collection, usage and disclosure policies and practices (including the data security practices) of other organizations, such as, Apple, Google, Microsoft, or any other operating system provider, wireless service provider or device manufacturer, including any personal data you disclose to other organizations through or in connection with WaiverKing’s services.

7. Security of Your Information. The security of personal data is a high priority at WaiverKing. We seek to use reasonable technical, administrative and physical safeguards to protect personal data within our organization. Unfortunately, no data transmission or storage system can be guaranteed to be 100% secure. As a result, while we strive to protect your personal data, you acknowledge that: (a) there are security and privacy limitations of the Internet which are beyond our control; (b) the security, integrity, and privacy of any and all information and data exchanged between you and us through the website cannot be guaranteed; and (c) any such information and data may be viewed or tampered with in transit by a third party.

8. IP Addresses and Cookies. Cookies are very small text files that are stored on your computer when you visit some websites.

We use cookies to help identify your computer, including where available, your IP address, operating system and browser type, for system administration so we can keep your activity secure, tailor your user experience and remember your preferences. This is statistical data and does not identify any individual. You are always free to decline our cookies if your browser permits, but some parts of our website may not work properly.

9. Your California Privacy Rights: Notice to California Customers and Opt-Out Information. Residents of the State of California, under certain provisions of the California Civil Code, have the right to request from companies conducting business in California a list of all third parties to which the company has disclosed certain personal data, as defined under California law, during the preceding year for third party direct marketing purposes. You are limited to one request per calendar year. In your request, you must supply appropriate evidence of your identity and attest to the fact that you are a California resident and provide a current California address for our response. You may request the information by writing to privacy@waiverking.com

Some web browsers incorporate a “Do Not Track” feature that signals to websites that you visit that you do not want to have your online activity tracked. California residents are entitled to know how WaiverKing, Inc. responds to “Do Not Track” signals. How browsers communicate the Do Not Track signal is not yet uniform, so a standard technological response has not yet been developed by the appropriate technology communities. For this reason, we do not respond to Do Not Track signals currently. To opt out of direct advertising on our website, please send a request to the address above. The effect of an opt-out will be to stop direct advertising, but it will still allow the collection of usage data for certain purposes (e.g., research, analytics, and internal online services operation purposes).

10. Privacy Shield Framework

10.1. WaiverKing Inc. complies with the EU-U.S. and Swiss-U.S. Privacy Shield Framework as set forth by the U.S. Department of Commerce regarding the collection, use, and retention of personal information transferred from the European Union and Switzerland to the United States. WaiverKing has certified to the Department of Commerce that it adheres to the Privacy Shield Principles. If there is any conflict between the terms in this privacy policy and the Privacy Shield Principles, the Privacy Shield Principles shall govern. To learn more about the Privacy Shield program, and to view our certification, please visit https://www.privacyshield.gov/

10.2. In compliance with the Privacy Shield Principles, WaiverKing commits to resolve complaints about our collection or use of your personal information. Any individual(s) with inquiries or complaints regarding our Privacy Shield policy should contact us at: privacy@waiverking.com

10.3. WaiverKing Inc. has further committed to refer unresolved Privacy Shield complaints to Judicial Arbitration and Mediation Services (JAMS), an alternative dispute resolution provider located in the United States. If you do not receive timely acknowledgment of your complaint from us, or if we have not addressed your complaint to your satisfaction, please visit https://www.jamsadr.com/eu-us-privacy-shield for more information or to file a complaint. The services of JAMS are provided at no cost to you. In certain situations, you may also have the right to pursue binding arbitration under the Privacy Shield Framework.

10.4. You may have the option to select binding arbitration for the resolution of your complaint under certain circumstances, provided you have taken the following steps: (1) raised your complaint directly with WaiverKing Inc. and provided us the opportunity to resolve the issue; (2) made use of the independent dispute resolution mechanism identified above; and (3) raised the issue through the relevant data protection authority and allowed the U.S. Department of Commerce an opportunity to resolve the complaint at no cost to you. For more information on binding arbitration, see U.S. Department of Commerce's Privacy Shield Framework: Annex I (Binding Arbitration).

10.5. For purposes of enforcing compliance with the Privacy Shield, WaiverKing is subject to the investigatory and enforcement authority of the U.S. Federal Trade Commission.

10.6. WaiverKing Inc. is controlled and operated by us from the United States. Except where you are a resident of a Member State of the EU, in which case paragraphs 2 and 3 above will apply, your personal data may be stored and processed in any country in which we engage service providers, and by using WaiverKing’s services you understand that your information may be transferred to countries outside of your country of residence, including the United States, which may have data protection rules that are different from those of your country. In certain circumstances, courts, law enforcement agencies, regulatory agencies or security authorities in those other countries may be entitled to access your personal data. Regardless of where your information is processed, we apply the same protections described in this policy.

11. Changes to the privacy policy. We reserve the right to change this policy at any time, without prior notice to you. Such changes, modifications, additions, or deletions shall be effective immediately upon notice thereof, which may be given by means including, but not limited to, issuing an e-mail to the e-mail address provided by you or posting the revised policy on this page. You acknowledge and agree that it is your responsibility to maintain a valid e-mail address and/or review the WaiverKing website and this policy periodically, and be aware of any modifications. Your continued use of the WaiverKing website after such modifications will constitute your: (a) acknowledgment of the modified policy; and (b) agreement to abide and be bound by the modified policy.

12. Our details

12.1. This website and software is owned and operated by WaiverKing Inc.

12.2. We are registered in the state of California under registration number C3518177, and our registered office is at 340 S Lemon Avenue, # 2018 Walnut, California 91789.

12.3. You can contact us:

a) by mail, using the postal address given above;

b) using our website contact form;

c) by telephone, on the contact number published on our website from time to time; or

d) by email, using the email address published on our website from time to time.

13. Data protection officer

Our data protection officer may be contacted via email: privacy@waiverking.com, or telephone: +1 (888) 211-6693.

Your browser is not supported. Please update your browser