Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Have you been referred by a doctor? (please list the name) *

Yes

No

Do you currently have any infection or malignant disease? *

Yes

No

I have read the questions on the form and answered them all honestly to the best of my knowledge. The therapist may contact my doctor for further clarification if needed and I hereby give my permission: *

Yes

No

I am aware that once the product is ordered, I cannot cancel the purchase. *

I accept

I am aware that the compression garment I may buy can't be returned. *

I accept

Please read carefully: *

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care.

I accept

24-hour Cancellation Policy *

I am aware that a 24-hour notice to cancel or re-book a service applies. If a reschedule of my appointment is placed less than 24 hours prior to the appointment or I do not attend my appointment on the day, I will be charged the full amount for the scheduled session.

I accept

Date

MM

DD

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