Biohacking Consent Form

Biohacking Consent Form

Client Name:

Provider Name:

Provider Address:

WHEREAS

WHEREAS, Participant desires to voluntarily receive biohacking services, protocols, and/or interventions described below from Provider; and

WHEREAS, Provider represents that it possesses knowledge, training, and facilities to administer such protocols, and that Participant has been afforded the opportunity to ask questions and receive answers regarding the nature and risks of such protocols; and

WHEREAS, the parties desire to set forth the scope, payment, confidentiality, risks, and other terms governing Participant's voluntary participation.

Scope of Work

Participant acknowledges and agrees that the Services may include, without limitation, dietary protocols, supplementation, neuromodulation, cryotherapy, intermittent hypoxia, wearable/implantable device use, experimental nutritional regimens, and other functional or experimental interventions as specified above. Participant acknowledges that certain protocols may be investigational in nature and that Provider has explained material differences between standard medical care and proposed protocols.

Payment Terms

Late Fee: Participant agrees that any payment not received within days after the due date shall incur a late fee equal to percent of the overdue amount per month, or the maximum allowed by applicable law, whichever is less. All fees are nonrefundable except as expressly provided in writing by Provider.

Term and Termination

Term: This Agreement shall commence on the Effective Date: , and shall continue until completion of the Services or termination as set forth below.

Either party may terminate this Agreement for any reason upon delivering written notice to the other party at least days prior to the proposed termination date. Provider may terminate immediately for safety concerns or material breach by Participant. Termination shall not relieve Participant of payment obligations for Services rendered prior to the effective date of termination.

Confidentiality

Each party agrees to keep confidential all proprietary or sensitive information disclosed by the other party in connection with the Services, including medical records, biometric data, experimental protocols, and business information, and to use such information only for purposes of performing under this Agreement. This obligation does not apply to information that (a) is or becomes public through no breach by the receiving party; (b) is lawfully obtained from a third party without restriction; or (c) must be disclosed pursuant to applicable law, regulation, or valid subpoena, in which case the disclosing party will provide notice to the other party to the extent permitted.

Risks, Acknowledgements and Consent

Participant acknowledges that biohacking interventions may carry risks, including but not limited to allergic reactions, infection, neurological effects, cardiovascular events, metabolic disturbance, and unforeseen or unknown adverse outcomes. Participant has had an opportunity to disclose medical history and ask questions.

Participant confirms the following (check all that apply):

I am not pregnant and will inform Provider immediately if I become pregnant.

I do not have contraindicated implanted medical devices unless previously disclosed.

I have obtained medical clearance from my treating physician if required by Provider or if I have significant medical conditions.

Participant voluntarily consents to the Services described in the Scope of Work and releases Provider, its employees, agents, and contractors from liability for ordinary negligence to the fullest extent permitted by law, while not waiving liability for willful misconduct or gross negligence. Participant understands that results cannot be guaranteed and that participation is voluntary.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the state in which Provider's principal place of business is located, without regard to conflict of laws principles. The parties agree that any dispute arising under this Agreement shall be resolved by the courts of that state unless the parties expressly agree otherwise in writing.

Entire Agreement

This Agreement, including any Scope of Work and payment schedule annexed hereto, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, proposals, and understandings, whether written or oral. Any modification to this Agreement must be in writing and signed by both parties.

Other Authorizations and Notices

Photography / Recordings: Participant consents to the taking of photographs, audio, or video recordings for the purpose of clinical documentation and program monitoring only if Participant checks the box below.

I consent to photographs and recordings for clinical documentation.

By signing below, Participant acknowledges that they have read and understand this Agreement, have had an opportunity to ask questions and receive answers, and voluntarily agree to participate in the Services under the terms set forth herein.

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