Seminars
Janet G. Travell, MD Seminar Series
Registration
Sample Waiver
Every effort is made to teach and practice safe techniques under the supervision of our instructors. Nevertheless, there is always the possibility of injury. Attendees will be required to sign a waiver absolving the Myopain Seminars, the program directors and the instructors of any liability in the event of injury. A sample of the waiver form follows:
I, ________________________ , understand that the Janet G. Travell, MD Seminar Series with Myopain Seminars is a participatory seminar program in which all persons attending the courses are expected to practice on each other. This means that I will allow my fellow participants as well as the workshop instructors to place acupuncture needles into various muscles throughout my body during the seminars.
I understand that although the risk of any serious harm is minimal, nevertheless there is the possibility of injury. Specifically, placing acupuncture needles or injections of local anesthetics into the body could possibly result in puncture of an organ such as the lung, the puncture of a vessel (artery or vein), or a nerve injury. Hematomas may occur and bruising may result. It is also possible that I may faint.
I understand the risk of complication, though small, is real. I hereby hold the program directors, Dr. Robert Gerwin, and Dr. Jan Dommerholt, the preceptors, Myopain Seminars, and Pain & Rehabilitation Medicine harmless for any injury sustained from dry needling during the course. Also, I hereby hold the program directors, Dr. Robert Gerwin and Dr. Jan Dommerholt, the preceptors, Myopain Seminars, and Pain & Rehabilitation Medicine harmless for any injury sustained from dry needling or injection techniques in my own practice.
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Signature and Date
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Witness Signature and Date
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