I hereby apply for bodywork or somatic education. I understand that the intent is to improve the functioning of my body and mobilize the energy; however, the work is not represented as a substitute for medical care.
I recognize that the process of this treatment necessitates that my body be touched, and I give permission to Alexandra Goldstein to touch my body. This consent form will apply to all Somassage®, treatment, or somatic education sessions from this date forward, unless revoked in writing.
I understand that I am responsible to wear an undergarment or shorts on my lower body and that if female, I will be provided with a tube top to cover my chest, and if male, I will be bare chested, unless I request to be covered. I also understand that I will be seen standing and walking in this attire.
I agree to be on time for my appointments and to accept financial responsibility for any appointments missed or cancelled without 24 hours notice. I understand that I could be charged a fee up to the full price of the scheduled appointment for late cancellations or no-show appointments.
I have received the Notice of Privacy Practices and have been provided an opportunity to review it.