Stargate Clinic PMA Intake and Consent

Private Membership Association Agreement

I voluntarily apply for and accept membership in the Stargate Clinic Private Membership Association (PMA).

By signing below, I agree that:

I am entering a private contract with Stargate Clinic to receive wellness-based services. These services are NOT medical in nature and do not replace or substitute for professional medical advice, diagnosis or treatment.

The PMA is governed by the laws of the State of Tennessee regardless of my place of residence.

I may withdraw my membership at any time by submitting a written request: SGC 2824 merchant Dr. Knoxville, Tn 37912

Nature of Services Provided

I understand that services provided by Stargate Clinic include non-invasive wellness modalities such as:

LifeWave phototherapy patches ( e.g., Ice Wave, X39 and Aeon)

Light therapy, frequency, and vibration-based interventions.

These services are provided exclusively to PMA members

and are not intended to diagnose, treat, or cure any medical

condition.

Product Disclosures

LifeWave IceWave, X39 & Aeon patches are investigational wellness products. These products are not FDA-approved medical devices or pharmaceuticals.

No guarantees, diagnoses, or cures are promised or implied.

Financial Agreement

The $25 membership fee is deferred at this time. This fee will only be charged if I choose to purchase a product or service. All services are private-pay only; insurance is not accepted.

Medical Screening Questionnaire (Check all that apply)

Video and Photo Consent

I authorize Stargate Clinic to capture and use video and/or photo images of me during participation in booth or clinic-based wellness activities. These may be used for: Educational demonstrations, public awareness campaigns, social media or marketing purposes.

I waive any rights to compensation or approval for future use.

I understand I may revoke this consent at any time in writing.

HIPPA Privacy Acknowledgment

I understand that my private health information will be treated with care and stored securely. Stargate Clinic will only use my information for services provided under this membership and will not release it to third parties without my written consent.

Disclaimers

These services are not intended to replace medical treatment by a licensed provider. No diagnosis or prescription is provided.

I understand that all services are provided through a Private Membership Association. My participation is entirely voluntary.

Signature and Date

I have read and understood this form. By signing below, I confirm

my voluntary membership in Stargate Clinic PMA and my consent to

receive wellness services as described above.