Series Consent

DateTime

I hereby apply for a standard series of Soma Neuromuscular Integration® sessions. I understand that the intent of SNI® is to improve the structure and functioning of my body, and that the work is not represented as a substitute for medical care. I understand that SNI® is specialized bodywork, performed by proficiently educated practitioners whose intention is to balance and integrate tissue and joints throughout the entire structure.

I understand that the standard process of SNI® consists of eleven basic sessions, and additional sessions if needed. I understand that neither the SNI® practitioner nor I is under any obligation to complete the entire series.

The following are specific consents required for the SNI® sessions. By initialing each, I am giving specific consent to Alexandra Goldstein for each treatment session, for the entirety of the treatment session.

Inititals*      I consent to work performed around and within the parameters of the perineal border (pelvic floor and associated structures of the gluteal cleft, coccyx and tip of coccyx, obturator attachments, pubis, pubic symphysis, and ramus) to facilitate the process of Soma Structural Integration.

Initials*   I consent to work performed in the nasal passage, oral passage, nasal cavity and oropharynx to facilitate the process of Soma Structural Integration.

Inititals*   I am responsible for wearing an undergarment or shorts on my lower body. If female, my breasts will be covered with a provided garment 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 understand that I can revoke the above consents either verbally or in writing at any time.

I agree to be on time for all appointments and to accept financial responsibility for any missed appointments or cancellations without 48 hours notice. I understand that I could be charged a fee up to the amount of the scheduled appointment for late cancellations or no-show appointments.

I have received the Notice of Privacy Policy and have been provided an opportunity to review it.

I have read and understood the above statements,

Signature: *

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Name *

First Name Last Name

Preferred Pronouns

Date of Birth

Date

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Please provide emergency contact information

Soma Neuromuscular Integration® Application and Consent