Hijama Relief will take legal action against copyright infringement on the content of the HijamaRelief.com website.
Hijama is Ineligible Expense for Health Reimbursement Accounts (HRAs), Health Savings Accounts (HSAs), and Flexible Spending Accounts. Hijama is a religious practice. The client fully understands that the services provided by Hijama Relief and/ or its representatives are not designed or intended to diagnose or cure a medical condition or to serve as a substitute for diagnoses or treatments determined by a licensed medical doctor, chiropractor, physical therapist, and/or any other licensed specialist, and I, the client, state and warrant that I am not seeking the services for medical diagnostic or treatment purposes. We do not prescribe any drugs or medications or recommend a change in dosage or discontinuation of any prescribed drug or medication. Conditions like, but not limited to, stroke, seizure, diabetes, psychotic disorders, hypotension, anemia, atrial fibrillation, hemophilia, sexually transmitted diseases, etc. must be disclosed before your session. Medications like type 1 and type 2 diabetes medications, anticoagulants, and antiplatelets must be disclosed. Every disclosure must be done in the appointment form while booking your appointment for Hijama. If you have a health emergency or need any medical treatment or opinion, you should consult your Primary Care Physician. I, the client, have read and understood the entire HijamaRellief.com website and acknowledge the Policy, What to do before and after Hijama, Side Effects, and the Disclaimer section of the Hijama Relief Website. I hereby request and consent to the performance of Hijama. I will never stop taking my medications prescribed by my Medical doctor even if I feel better after Hijama, without my doctor’s prior permission. The content of this website should not be taken as medical advice. This website is for informational purposes only. This is a Wellness Services Agreement WHEREAS the Parties to this Agreement share the belief that it is every person’s right to seek the health and wellness services of, their choice, and rely further upon their rights protected by the U.S. Constitution to enter into private relationships and contracts of their choosing; Under the right to religious beliefs and practices. It’s the client’s sole responsibility to seek appropriate medical care in place of the services provided by the Hijama Practitioner. I acknowledge that the practitioner does not provide any guarantee or warranty as to the success of any suggestions, protocols, or products provided by the practitioner; and the client further agrees to legally release the practitioner of any responsibility for the healing process and possible legal action. This means the Client releases, waives, discharges, and covenants not to sue the practitioner from any liability, claims, demands, actions, and causes of actions whatsoever related to any loss, damage, or injury that may be sustained. The parties agree that recovery of the prevailing party pursuant to any action brought under this agreement, whether through private settlement or arbitration, shall be limited to the complaining party’s actual provable loss. Actual provable loss is defined as the total dollars expended by the client or due to the practitioner for services and products rendered. Hijama wet cupping is not a licensed medical practice by the state. The client understands that it is upon the client to provide written consent from his/her medical doctor to undergo Hijama if the client has any serious medical condition that warrants the doctor’s prior approval of Hijama. Both the Practitioner and the client agree that Hijama is deemed a religiously recommended therapy in Islam as stated in over 77 Hadith. Therefore, Hijama is considered an act of worship. Because Hijama can yield health benefits, that does not mean that we practice any form of medicine. The benefits of Hijama have not been evaluated by the Food and Drug Administration. The Practitioner will use a single-use blade, to make incision on the body to draw an amount of blood according to their professional discretion. Despite being very rare, persistent scratches could occur, in some cases indefinitely; syncope, nausea, drowsiness, somnolence, sedation, and vomiting are all rare but possible during and after Hijama. The client is advised to exercise caution as Hijama can temporarily affect his/her ability to drive a vehicle or operate heavy machinery safely. The client understands that his medical condition should be managed and controlled by his/her physician before considering Hijama. Phone calls, emails, and text messages can be recorded for quality and legal purposes. Terms and conditions are subject to change without prior notice. In cases where the client requests a Hijama that addresses enlarged prostate or Poly Cystic Ovarian Syndrome from a naturopathic standpoint, Cups will be placed on the pubic symphysis area, This will not be considered improper genital contact. Client’s body will be covered in various areas, including areas not treated by Hijama with disinfectants and sanitizers like, but not limited to (iodine, chloroxylenol, isopropyl alcohol), with a blend of oils like, but not limited to (Black Seed oil, Mint oil, Olive oil, and Essentials oils), with Herbs, gel and other ingredients not listed here. Allergic reaction to an essential oil is called contact dermatitis. It could occur in the form of an itchy, red rash on your skin typically where the oil has been applied. Keloid formation possibility exists for some individuals. The client takes full responsibility for Hijama treatment and has chosen to undertake Hijama. Hijama is a spiritual, religious, natural, holistic means of detoxification, healing, and pain management. It does not involve examination, diagnosis, or treatment of any mental or physical illness or disease or prescription medication of any kind. Hijama-Relief considers Hijama an act of worship as a recommended practice in the Muslim Faith, stated and established in over 77 different Hadith. Yet, with open heart, hand, and mind we accept clients from all different backgrounds with full respect, honor, and dignity. The practitioners of Hijama Relief do not assume and hereby disclaim any liability to any party for any loss, damage, or disruption caused by errors Whether such errors result from negligence, accident, or any other cause. the information on this website it’s for educational and informational purposes only. the client must only consult with their physician for diagnosis and treatment of any health-related problems. We are not responsible for any health or allergy needs that may require medical supervision and we are not liable for any damage or negative consequences from any treatment, action, application, or preparation to any client reading or following the information on this website. This website is never intended as a substitute for the medical advice of Physicians. You are entering here a private agreement with the HijamaRelief Association, where services are not offered to the general public, and by filling out the form and getting Hijama performed, you are a member of the HijamaRelief Association. It is the client’s sole responsibility to seek approval from their physician before pursuing Hijama or cupping. Services administered by Hijama Relief are non-medical. They are not intended to diagnose, treat, or correct any ailment, disease, disorder, syndrome, symptom or condition of any kind. Only licensed healthcare professionals can provide medical treatments. This is a strictly religious and holistic remedy, per the guidelines of the Sunnah of Prophet Muhammad, pbuh. Certified Hijama Practitioner is not a Licensed Medical Doctor, Licensed Acupuncturist, Massage Therapist, or any other Medical/Health Professional. We do not diagnose, treat, or cure clients and we do not prescribe any medications to clients. We are not qualified or licensed in the field of nutrition, herbs, and/ or fitness. Clients should consult with their Licensed Physician before reducing, weaning off, or stopping prescribed medications even if they feel better. At Hijama Relief, We do not practice medicine. More specifically, We do not examine, diagnose, treat, offer to treat, cure, or attempt to cure any physical or mental disease or disorder, or any physical deformity or injury. Again, We do not prescribe any drugs or medications or recommend a change in dosage or discontinuation of any prescribed drug or medication. If you have a health emergency or need any medical treatment or opinion, you should consult ONLY with your Primary Care Physician. The content of this website should not be taken as medical advice. This website is for informational purposes only. Skin discoloration is an Ecchymosis, not a Hematoma, created by cupping. It is caused by increased blood circulation and vasodilation of the blood vessels subcutaneously (due to the negative pressure applied by the cups.) We do not practice Surgical, Medical, or Emergency Cupping Therapy. We intentionally refrain from posting pictures of Hijama Blood on our website out of respect for our Hemophobic clients.
I UNDERSTAND AND AGREE, ON BEHALF OF MYSELF, MY HEIRS, ASSIGNS, PERSONAL REPRESENTATIVES AND
NEXT OF KIN THAT MY EXECUTION OF THIS DOCUMENT CONSTITUTES:
1. AN UNQUALIFIED ASSUMPTION BY ME OF ALL RISKS associated with my Hijama procedure even if arising from
the negligence or gross negligence of the Releasees, as that term is defined below;
2. A FULL AND FINAL RELEASE AND WAIVER OF LIABILITY AND ALL CLAIMS that I have, or may in the future have,
against Hijama Relief or its representatives, his executors, administrators, heirs, successors, assigns, any related professional corporations, employees, agents, and representatives (collectively referred to as the “Releasees”) from any liability for any
loss, damage, injury, or expense that I may suffer as a result of my Hijama procedure, due to any cause whatsoever, including negligence, gross negligence, breach of contract, or breach of any statutory or other duty of care;
3. AN AGREEMENT NOT TO SUE THE RELEASEES for any loss, injury, costs, or damages of any form or type, howsoever caused or arising, and whether directly or indirectly from my participation in Hijama.
4. AN AGREEMENT TO INDEMNIFY, and to SAVE and HOLD HARMLESS the Releasees, and each of them, from any
litigation expense, legal fees, liability, damage, award, or cost, of any form or type whatsoever, they may incur due to
any claim made against them or any one of them by me or on my behalf, or that of my estate, whether the claim is
based on the negligence or the gross negligence of the Releasees or otherwise as stated above, and I HAVE READ AND UNDERSTOOD THIS AGREEMENT AND I AM AWARE THAT BY SIGNING THIS AGREEMENT I AM
WAIVING CERTAIN SUBSTANTIAL LEGAL RIGHTS WHICH I AND MY HEIRS, NEXT OF KIN, EXECUTORS,
ADMINISTRATORS AND ASSIGNS MAY HAVE AGAINST THE RELEASEES.
I SIGN THIS DOCUMENT VOLUNTARILY AND WITHOUT INDUCEMENT.
COVID-19 Liability Release Waiver
The World Health Organization has declared the novel Coronavirus (COVID-19) a worldwide pandemic. Due to its capacity to transmit from person to person through respiratory droplets, the government has set recommendations, guidelines, and some prohibitions to which Hijama Relief adheres.
I acknowledge that I have read the foregoing Liability Release Waiver and understand its contents; that I am at least eighteen (18) years old and fully competent to give my consent; That I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my free act and deed; that I give my voluntary consent in signing this Liability Release Waiver as my free act and deed with full intention to be bound by the same, and free from any inducement or representation.
This waiver will remain effective until laws and mandates relevant to COVID-19 are lifted.
Agreement for Wellness Services
Definitions: All words and statements in this Agreement should be interpreted as written in simple, common language. The practitioner is referred to as “Practitioner” and “Practitioner’s”; you, the receiver of Practitioners services, are referred to as “Client” or “Client”; the term “Party” refers to the indicated party; the term “Parties” always refers to the both, the Practitioner and you, the Client, jointly; and, “PMA” refers to the Pastoral Medical Association. WHEREAS The Parties to this Agreement share the belief that it is every person’s right to seek the counseling, associated wellness services, and products of their choice; and relying further upon their rights to enter into private relationships and contracts of their choosing; AND WHEREAS, the Parties hereto desire that this Agreement shall establish a private contractual relationship between the Parties for the purposes stated under Section 2 below; NOW THEREFORE, in consideration of the mutual covenants contained in this Agreement and for other good and valuable consideration, the adequacy and receipt of which is acknowledged;
IT IS HEREBY AGREED AS FOLLOWS:
1. Exclusive Agreement: The Parties acknowledge and agree that this Agreement is a contract that shall govern the Party’s private relationship for counseling, associated wellness services, and products as defined herein, and shall supersede any wellness or financial agreement for such same services written or oral; and, should any other agreement be executed between the Parties, now or later, for any service that is defined under this Agreement, and should any terms and conditions of any such other agreement(s) conflict with the terms and conditions herein, Parties agree that this agreement shall predominate and control.
2. Services Provided: Under this Agreement, the Practitioner provides counseling and associated wellness services and products, that are solely intended to improve physical, mental, and spiritual wellness; are provided in a ministerial-based counselor-counselee private
relationship; are not provided in a doctor-patient relationship; are not state-licensed counseling, medical, chiropractic, or diet and nutrition services; do not include activities, products, or substances that are regulated by governmental agencies; and, do not include diagnosing, treating, or curing, or attempting to diagnose, treat or cure any illness or disease or condition, or otherwise
that constitute the practice of medicine.
3. Practitioner Agrees: To voluntarily enter into the contractual private relationship formed by this Agreement; to carry out all responsibilities under this Agreement faithfully and to the best of Practitioner’s ability; to fully disclose Practitioner’s education and experience in the services to be provided, upon Client’s request; to use Practitioners’ best efforts to formulate a protocol to assist Client in achieving Client’s desired wellness goals; and, to deliver and perform counseling, associated wellness services and products, ethically and professionally.
4. Client Agrees: and acknowledges that Practitioner is a ministerial provider and voluntarily enters into the contractual relationship formed by this Agreement to receive Practitioner’s services as defined under Section 2; to carry out all responsibilities under this Agreement faithfully and to the best of Client’s ability; to request all information Client deems necessary to determine whether Practitioner’s education, (that may or may not have been received from a governmental accredited university), services and cost are suitable to Client; to fully disclose to Practitioner all pertinent information requested to assist the Practitioner in helping client; to meet at the agreed appointment times and pay the agreed charges in a timely manner; and, that it is Client’s sole responsibility to seek appropriate medical advice to assure that these nonstate licensed, ministerial based counseling and associated wellness services and products are suitable for Client, or to seek the appropriate medical care in the event illness, disease or other adverse conditions are suspected, known or become suspected or known, before or while receiving Practitioner’s services.
5. No Warranty, Independent Practitioner, and Indemnification: The client acknowledges and agrees that the Practitioner does not provide any guarantee, warranty, or refund for counseling, or associated wellness services or products, or for the success of any counseling, service, or product. Therefore, Client agrees to indemnify and hold Practitioner harmless for counseling, associated wellness services, and products provided by Practitioner, or for Client’s or another’s failure to achieve desired wellness outcomes. Parties also acknowledge and agree that the Practitioner is an independent practitioner and not an employee or agent of the PMA, and that the Practitioner is solely responsible for the Practitioner’s actions, business, counseling, associated wellness services, and products. Therefore, Parties hereby agree to indemnify and hold PMA harmless for any claims or actions, counseling, wellness services, or products provided by Practitioner, or on the
failure of the Client or another under the Client’s charge to achieve desired wellness outcomes.
6. Records and Confidentiality: The Parties acknowledge and agree that any records that may be maintained by the Practitioner are ministerial-based private counseling and wellness records and not medical records. Therefore, the Parties agree that such records may not in any case be released as medical records. Practitioner further agrees that Client’s records are confidential and the content of such records may not be divulged by Practitioner to any other Party; except at the request of Client to release records of Client or another in Client’s charge; or by Practitioner’s policy wherein proper reporting may be made in the event Practitioner
believes any person is at risk of harm, or has been harmed, or as may be required in the jurisdiction where services are provided.
7. Complaints and Grievances: The Parties acknowledge and agree that both shall use their best efforts to resolve any complaint, grievance, or dispute privately by the terms and conditions hereunder and that if private resolution fails, the sole recourse shall be resolution through arbitration by a qualified arbitrator mutually agreed upon by the Parties. It is further understood and agreed that decisions pursuant to arbitration shall be final and binding on the Parties and that the Jurisdiction for enforcement of arbitration decisions shall be the state or jurisdiction where services were or are provided.
8. Limit to Recourse: Parties agree that recovery to the prevailing Party pursuant to any action brought under this Agreement, shall be by the terms and conditions hereunder, and whether through private resolution or arbitration, shall be limited to the actual provable amount, plus reimbursement of expenses incurred to enforce this Agreement. For purposes of this agreement, the actual provable amount is defined as the recorded total dollars expended or due from Client to Practitioner, or due to Practitioner from Client.
9. Term, Termination, and Survival: This Agreement shall become effective when signed below and shall continue in effect until terminated by either Party, by Notice as specified under Section 13. Upon termination by either Party, the Indebtedness of Client to Practitioner for services not yet received shall cease on that date. Termination shall not relieve the Parties from any debt incurred for counseling, services or products agreed and rendered before termination, or from any terms, conditions, agreements, responsibilities, or indemnifications (as provided in Section 5), hereunder, and those terms, conditions, agreements, debts, responsibilities and indemnifications shall survive any termination.
10. Amendments: Any amendment to this Agreement must be in writing and signed by both Parties. Parties understand and agree that Section 5 herein regarding Indemnification of the PMA, may not be waived, modified, or otherwise altered.
11. Severability: In case any provision in this Agreement shall be held invalid, illegal, or unenforceable, the validity, legality, and enforceability of the remaining provisions shall not in any way be affected or impaired thereby.
12. Capacity to Contract: Parties represent that each is of legal adult age and can understand, execute, and perform according to the terms of this Agreement. If any services under this Agreement are to be provided to a minor person under legal consenting age, said minor’s name shall be written below with Client’s name and signature, and Client hereby attests that Client is the legal guardian of said minor with full authority to make counseling and associated service or product decisions for such minor person.
13. Notices: All notices, requests, consents, demands, and other communications under this Agreement shall be in writing and shall be deemed to have been duly given on the date of service if served personally on the Party to whom notice is to be given, on the date of transmittal of services via facsimile or electronic mail to the Party to whom notice is to be given, or on the third day after mailing if mailed to the Party to whom notice is to be given by first class mail.
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Practitioner Name Date Practitioner Signature
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Client Name Date Client Signature
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