Consent & Waiver Form
Terms and Conditions
USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
I provide consent to DexaFit Boston and/or DexaFit, Inc. for the use of their DXA scanner to conduct body composition and/or bone densitometry scans, acknowledging the use of low-dose x-rays in the technology.
RECORDS REVIEW FOR RESEARCH
I also grant DexaFit Boston and/or DexaFit, Inc. permission to utilize or review my de-identified records for research purposes, and to assess my eligibility for approved clinical studies, allowing them to contact me if I qualify as a research candidate.
ADDITIONAL SERVICES AND TESTING
In conjunction with DXA scans, DexaFit Boston and/or DexaFit, Inc. offers a comprehensive suite of services crafted to enhance your wellness journey:
RMR Testing (Resting Metabolic Rate): DexaFit Boston and/or DexaFit, Inc. introduces Resting Metabolic Rate testing services, a method for determining the caloric requirements of the body at rest. I willingly provide consent for the administration of this test, recognizing its role in tailoring wellness strategies. I acknowledge that DexaFit is not liable for any inaccuracies in the RMR test reports or any consequences resulting from following advice based on these reports.
The attainment of nutritional objectives is contingent upon the client's dedication and adherence to recommendations of their health care professionals. While DexaFit Boston and/or DexaFit, Inc. is committed to delivering professional guidance, individual outcomes may vary based on personal choices and other contributing factors.
It is explicitly acknowledged that DexaFit Boston and/or DexaFit, Inc. bears no liability for outcomes or consequences resulting from nutrition counseling sessions. The client assumes full responsibility for achieving desired nutritional outcomes.
VO2max Testing
Consent Form for VO2max:
Purpose and Explanation for the Test:
You will perform a graded exercise test on a motor-driven treadmill or stationary assault bike. The exercise intensity will begin at a low level and advance in stages, depending on your fitness level. The test may be stopped at any time due to signs of fatigue, changes in heart rate or blood pressure, or any symptoms you may experience. You may stop the test at any time due to feelings of fatigue or discomfort.
Attendant Risks and Discomforts:
As with any exercise, there exists the possibility of certain changes occurring during the test, including abnormal blood pressure, fainting, irregular, fast, or slow heart rhythm, and, in rare instances, heart attack, stroke, or death. Please note that there will NOT be a physician present on-site.
You and your own Doctor should evaluate the information you possess about your health status or previous experience with exercise-related or heart-related symptoms (such as shortness of breath with low-level physical activity, pain, pressure, tightness, or heaviness in the chest, neck, jaw, back, and/or arms) that may affect the safety of your test. Your prompt reporting of these and any other unusual feelings during the test is of great importance. You are responsible for consulting with your own doctors before taking the test.
Inquiries
Any questions about the procedures used in the exercise test or the results of your test are encouraged. If you have any concerns or questions, feel free to ask via email at support@dexafit.com prior to the test.
Voluntary Participation & Assumption of Risk
I acknowledge that I am voluntarily undertaking a graded exercise (“VO₂ max”) test conducted by DexaFit Boston, LLC and/or DexaFit, Inc. (“DexaFit”). I understand the test involves progressively strenuous activity on a motor‑driven treadmill or stationary assault bike without a physician on site and that inherent risks include, but are not limited to:slips, trips, falls, or ejection from the treadmill / bike;
muscle strains, sprains, ligament or tendon tears, bone fractures, impact injuries, and bruising;
dizziness, fainting, dehydration, heat illness, nausea, or vomiting;
abnormal blood‑pressure responses, arrhythmias, angina, heart attack, stroke, cardiac arrest, or sudden death; and
any aggravation of pre‑existing medical conditions.
I freely and knowingly assume all such risks, whether foreseeable or unforeseeable, that may arise from or be connected in any way to my participation.
Release of Liability & Covenant Not to Sue
To the fullest extent permitted by applicable law, I hereby waive, release, discharge, and forever covenant not to sue DexaFit, its owners, directors, officers, employees, contractors, agents, successors, and assigns (collectively, the “Released Parties”) from any and all claims, demands, actions, causes of action, damages, losses, costs, or expenses—including attorneys’ fees—of any nature whatsoever (collectively, “Claims”) arising out of or related to:my participation in the VO₂ max test;
any injury (physical, psychological, or otherwise), illness, disability, property damage, or death sustained during or after the test; or
the ordinary negligence, acts, or omissions of any of the Released Parties.
This waiver expressly covers—but is not limited to—Claims arising from falling off the treadmill or bike, equipment failure, misadjustment or misuse of equipment, inadequate instructions or supervision, emergency‑response delays, or inaccurate test results or interpretations.
Indemnification
I agree to indemnify and hold harmless the Released Parties from any Claim brought against them by me, my estate, my heirs, or any third party arising from my participation, except to the extent caused by the Released Parties’ gross negligence or willful misconduct.Governing Law & Severability
This Addendum is governed by the laws of the Commonwealth of Massachusetts. If any portion is held invalid, the remainder shall remain in full force and effect.I HAVE READ, UNDERSTAND, AND VOLUNTARILY AGREE TO THIS ADDENDUM.
I certify that I am at least 18 years old (or have obtained a parent/guardian signature) and that I have consulted my own medical professional regarding my suitability for this test.
In appreciation of the comprehensive services offered by DexaFit Boston and/or DexaFit, Inc., I embrace these offerings with confidence in the commitment to client well-being. I understand the nature of each service and acknowledge the terms outlined herein.
Please note that DEXA body composition results are subject to variability due to a number of factors. While DEXA is a highly accurate method for estimating body fat, lean mass, and bone density, results are not absolute and should be interpreted as estimates.
Specifically, regional body composition values (arms, legs, trunk, etc.) may vary between scans due to:
Slight changes in body positioning during the scan,
Variations in Region of Interest (ROI) placement by the technician or software,
Hydration status, recent food intake, and other biological factors,
Differences in machine calibration or environmental conditions.
I understand that DexaFit Boston and/or DexaFit, Inc. does not provide diagnostic medical advice, and does not guarantee the accuracy, completeness, or clinical interpretation of DXA scan data. I acknowledge that interpretation of scan data is solely my responsibility and should be done in consultation with a licensed healthcare provider. I waive any liability claims related to the accuracy or interpretation of data provided.
I acknowledge that DXA body composition results, including measurements of fat mass, lean mass, and bone density, may vary due to physiological factors, hydration, positioning, and technical margin of error. I understand that variations are considered normal and acceptable in such scans. I agree that DexaFit is not responsible for any consequences resulting from such variations, and I waive any claim to refunds or legal action based on these results.
Scope of Services
DexaFit collects and transmits data only; we do not diagnose, treat, or prescribe. Any interpretation of your results must be performed by a licensed healthcare professional of your choice
FINANCIAL RESPONSIBILITY:
I hereby acknowledge and assume full financial responsibility for all charges related to the services provided to myself, my family members, and/or my responsible parties at DexaFit Boston. I understand and agree that all payments are non-refundable, and I explicitly waive any right to dispute transactions.
In the event of a cancellation within a 24-hour period preceding the scheduled appointment,
I acknowledge that no refunds will be issued. Additionally, I commit to paying a $50 rescheduling fee for any changes made within a 24-hour timeframe from the scheduled appointment. There will be no refund issued for no-show appointments. Furthermore, no refund will be issued if any test part of a bundle is rescheduled and subsequently canceled. I agree and acknowledge that appointments made for special events can not be rescheduled to another day.
Furthermore, I recognize that should I choose to reschedule within 24 hours of the appointment and subsequently cancel, I am obligated to pay the complete value of the service along with an additional rebooking fee.
DexaFit Boston Unlimited and Live Well Subscription Terms:
I understand that the DexaFit Boston Unlimited/Live Well Subscription is for the exclusive use of one person only, the subscriber. In the event that the subscription is used by someone other than the subscriber, I agree to pay a minimum fee of $500, up to the cost of individually booked, daily Red Light Therapy sessions, 3D Body Scans, or DEXA Body Composition Scans for one year, at the discretion of DexaFit Boston. I explicitly waive any right to dispute this charge in court or with credit card processing companies or any other institution.
I understand that cancellations require a 30-day notice. If my renewal date passes after the 30-day notice period, I acknowledge and agree that I will be charged for one more subscription period.
By accepting these terms, I affirm my dedication to meeting the financial obligations associated with the services provided.
Access to DexaFit Services
I understand that there are risks presented by participating in using DexaFit Boston Services including receipt by me of information about my health and fitness (such as metabolic characteristics) that I would prefer not to know, and which may indicate conditions or problems that may be upsetting to me or even incurable, and I assume those risks.
I understand that should I use the DexaFit DXA scanner to perform a body composition analysis, I do so with full knowledge and awareness that this technology uses low-dose x-rays. I acknowledge that I am not pregnant and am eligible to perform the DexaFit DXA scanner.
I understand that should I perform the VO2 Cardio Fitness test, I hereby consent to engage voluntarily in the test in order to determine my circulatory and respiratory fitness. Before I undergo the test or fitness program, I certify that I am in good health and capable of conducting the VO2max test.
I understand that I am responsible for monitoring my own condition throughout the exercise test or fitness program and should any unusual symptoms occur, I will cease my participation and inform the DexaFit staff of my symptoms. I understand that the reaction of my heart, lungs, and blood vessels to such exercise cannot always be predicted with accuracy. I know there is a risk of certain abnormal changes occurring during or following exercise which may include abnormalities of blood pressure or heart rate, ineffective function of the heart and in rare instance, heart attack or death. Use of strength equipment can lead to musculoskeletal strains, pain and injury.
WAIVER AND AGREEMENT
I release all representatives of DexaFit Boston and/or DexaFit, Inc. from any responsibility or liability for injury or damage to myself, including those caused by the negligent acts or omissions of those mentioned or others acting on their behalf, arising out of or connected with my participation in services, activities, or programs of DexaFit Boston and/or DexaFit, Inc.
I am voluntarily participating in the DexaFit Boston and/or DexaFit, Inc DXA scan service and/or other services, including 3D scans, RMR and VO2max Metabolic Analysis, Red Light Therapy, Training Programs, and nutritional/meal planning consultation, and all other services performed by DexaFit Boston. I expressly assume all risks of injury and death resulting from participation in the aforementioned services.
I declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that disqualifies me from receiving a DXA scan from DexaFit Boston and/or DexaFit, Inc. I acknowledge that I have permission to participate or have decided to participate in these services without the approval of my physician, assuming all responsibility for my participation. I also certify that I am not pregnant or trying to become pregnant.
I take full responsibility for any action taken by me after my visit to DexaFit Boston and/or DexaFit, Inc. I do not hold any representatives of DexaFit Boston or DexaFit, Inc responsible or liable for any adverse effects or complications arising from the services or opinions offered by them.
Confidentiality: Information based on the observations made during the DXA scan, VO2max, or RMR analysis, and subsequent reports are treated as privileged and confidential. However, it may be used for statistical or scientific purposes while retaining your right to privacy.
I understand that DexaFit Boston and/or DexaFit, Inc does not diagnose or interpret the DXA results, and that any further review or analysis of the report is between the individual and their primary care physician.
CLIENT HIPAA CONSENT FORM
I understand that I have certain rights to privacy regarding my protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). By signing this consent, I authorize DexaFit Boston and/or DexaFit, Inc to use and disclose my protected health information to carry out:
Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
Obtaining payment from third-party payers (e.g. my insurance company)
The day-to-day operations of DexaFit Boston practice.
I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that DexaFit is not required to agree to these requested restrictions. If agreed, DexaFit is bound to comply with these restrictions.
I may revoke this consent in writing at any time, but any use or disclosure before the date of revocation is not affected.
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
I authorize DexaFit Boston and/or DexaFit, Inc to forward the health and fitness information resulting from their services to me or any parties authorized by me through email, fax, mail, or the private login page on the DexaFit website. This Authorization is subject to revocation/withdrawal in writing by me to DexaFit Boston, except for actions already taken to release this information. This Authorization shall remain valid unless revoked, and DexaFit Boston and/or DexaFit, Inc will not forward my health and fitness information if I do not consent to this Authorization.
I attest that I am NOT pregnant and 350 pounds and have read and agreed to the above, consenting to participate in the services rendered by Dexafit Boston.
No Medical or Health Services.
I understand that DexaFit Boston is not a Health Advisor and does not provide medical, health or other professional services or advice. DexaFit performs services and works together with Wellness Providers and Subscribers to facilitate data gathering and conducting data analyses that may help Wellness Providers and Subscribers work together to help Subscribers take a more active role in their well being.
DexaFit Boston does not practice medicine or any other licensed profession, and does not interfere with the practice of medicine or any other licensed profession by Wellness Providers, each of whom is responsible for his or her services and compliance with the requirements applicable to his or her profession and license.
Consent Form for VO2max:
Purpose and Explanation for the Test:
You will perform a graded exercise test on a motor-driven treadmill or stationary bike. The exercise intensity will begin at a low level and advance in stages, depending on your fitness level. The test may be stopped at any time due to signs of fatigue, changes in heart rate or blood pressure, or any symptoms you may experience. You may stop the test at any time due to feelings of fatigue or discomfort.
Attendant Risks and Discomforts:
As with any exercise, there exists the possibility of certain changes occurring during the test, including abnormal blood pressure, fainting, irregular, fast, or slow heart rhythm, and, in rare instances, heart attack, stroke, or death. Please note that there will NOT be a physician present on-site.
You and your own Doctor should evaluate the information you possess about your health status or previous experience with exercise-related or heart-related symptoms (such as shortness of breath with low-level physical activity, pain, pressure, tightness, or heaviness in the chest, neck, jaw, back, and/or arms) that may affect the safety of your test. Your prompt reporting of these and any other unusual feelings during the test is of great importance. You are responsible for consulting with your own doctors before taking the test.
Inquiries
Any questions about the procedures used in the exercise test or the results of your test are encouraged. If you have any concerns or questions, feel free to ask via email at support@dexafit.com prior to the test.
I hereby consent to engage in an exercise test to determine my exercise capacity. My permission to perform this test is given voluntarily. I understand that I may stop the test at any point if I so desire. I have read this form and understand the test procedures I will perform and the attendant risks and discomforts. I understand that there will NOT be a supervising physician onsite. Knowing these risks and discomforts, and having had an opportunity to ask questions that have been answered, I consent to participate in the test.
No Warranties.
ALL SERVICES AND PRODUCTS PROVIDED BY DEXAFIT ARE PROVIDED "AS-IS" WITHOUT ANY WARRANTY EXPRESS OR IMPLIED, AND DEXAFIT DISCLAIMS ALL IMPLIED WARRANTIES, INCLUDING ANY IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A SPECIFIC PURPOSE. Without limiting the preceding sentence, I acknowledge and agree that DexaFit is not responsible for the actions or omissions of my Wellness Providers or Testing Laboratories.
Referral Program
The referral program applies only to new client bookings.
Referral codes must be entered at the time of booking to be valid.
Clients cannot cancel an existing appointment and rebook using a referral code. Doing so will result in the forfeiture of the referral prize, and no refund will be provided for the initial appointment.
The referral prize (complimentary DexaFit Body Scan) is awarded only after successfully referring 5 individuals who complete their bookings.
If a client cancels their appointment, they forfeit the referral prize, even if the required referrals have been achieved.
Referral codes are unique to each client and are based on their phone number without punctuation.
DexaFit Boston reserves the right to modify or terminate the referral program at any time.
The referral prize has no cash value and is non-transferable.
DexaFit Boston is not responsible for any technical issues or delays in the referral tracking system.
Limit 4 free scans per year
Other terms and conditions may apply. Please contact DexaFit Boston for any further clarification.
By participating in the DexaFit Boston Referral Program, clients agree to abide by these terms and conditions. DexaFit Boston reserves the right to interpret these rules and make decisions at its discretion.