History of Pathology

Please check any symptoms that apply to you and indicate right or left when applicable:

As a customer of A Wild Physique, your privacy is important and guaranteed. Your personal information is never shared and/or distributed to outside parties. We take great precautions protecting your information using Secure Socket Layer (SSL) which is encryption technology that protects sensitive information such as credit card information. These secure networks protect personal information and only a limited number of persons with special access have rights to networks, and are required to keep information confidential. We will not sell your information.

Myofascial Release Treatment  Policies: Client services and chart information are confidential. Written authorization is required from you to release any

• Please turn off your cell phone for optimal relaxation       

• Your scheduled session is set aside for you. We do not double book appointments     

 • Please reschedule your session if you are more than 15 minutes late   

• 24 hour cancellation notice is required to avoid being charged for your session   

• At no time will genitalia or breast tissue be exposed      

• You will have a consultation with your therapist to discuss your session

• I understand that my therapist or I may end the session at any time and at any moment

• Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law 

 

Client Agreement: 

I understand that we do not diagnose illness, disease, any physical or mental disorder, nor do we prescribe medical treatment, pharmaceuticals, or perform joint mobilization. I acknowledge that myofascial release treatment is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service. It is my choice to receive myofascial release treatment. I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction. I also understand that at any time I feel pain or discomfort during the session, I will immediately inform my therapist so they can adjust.  I have stated my pertinent medical conditions, and will update the therapist of any changes in my health status. I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless A Wild Physique, LLC d/b/a A Wild Physique Wellness Club, and their officers, officials, and/or employees, and other participants from any liability whatsoever arising from failure on my part.

Waiver / Release for Communicable Diseases Including COVID-19 ASSUMPTION OF RISK / WAIVER OF LIABILITY / INDEMNIFICATION AGREEMENT

In consideration of being allowed to participate in A Wild Physique workout programs, Myofascial Release Treatment, and related events and activities, the undersigned acknowledges, appreciates, and agrees that:

1. Participation includes possible exposure to and illness from infectious diseases including but not limited to MRSA, influenza, and COVID-19 and its variants. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist; and,

2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown and assume full responsibility for my participation; and,

3. I willingly agree to comply with the stated customary terms and conditions for participation as regards protection against infectious diseases. If, however, I observe any unusual or significant hazard during my presence or participation, I will remove myself from participation and bring such to the nearest official immediately; and,

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HERBY RELEASE AND HOLD HARMLESS A Wild Physique and their officers, officials, and/or employees, other participants, (RELEASEES), WITH RESPECT TO ANY AND ALL ILLNESS, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IF FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Photography/Video Release

Participants involved in any activities offered by A Wild Physique may be photographed or videotaped during training and/or myofascial release treatments. The undersigned hereby consents to the use of these photographs and/or videos without compensation on A Wild Physique website or in any editorial, promotional or advertising material produced and/or published by A Wild Physique.

I have read and understood the foregoing assumption of risk, and release of liability and I understand that by signing it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my negligent or intentional act or omission, I understand that by signing this form, I am waiving valuable legal rights.
By signing below, the signee has read, understands and agree to the above the terms.