Childcare Form

Who referred you to Kashmir Hands - Dina Giugliano?

NAME: PLEASE ENTER THE EXACT NAME THAT IS ON YOUR LICENSE

PHONE #(s)

BIRTH DATE:

Date

OCCUPATION:

FULL ADDRESS

We never sell, rent or share email address or other personal information with anyone. Is it ok to include your email on our mailing list?

Yes or No

Email Address:

In case of emergency, contact:

Emergency Contact Phone #:

Why did you choose this Continued Education Course?

If you are a Licensed Massage Therapist, please list License #(s) and State(s) your are Licensed:

Please list any other modalities you certified in treating clients with:

PLEASE TAKE A MOMENT TO READ CAREFULLY THE FOLLOWING INFORMATION AND SIGN WHERE INDICATED. THANK YOU.

If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary provider may be required prior to your service. I understand that massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I immediately inform the therapist so that the reassure 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 a medical examination, diagnosis or treatment and that I should consult a physician or other qualified specialist for any mental or physical ailment that I am aware of. 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 Dina Giugliano, Kashmir Hands Inc. therapists updated to any changes in my medical profile and understand that there shall be no liability on the therapists part should I neglect to do so. It is also understood 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

Client Signature:

Date:

Date

Cancellations/Transfers/Refunds: Fees are non-refundable and non-transferable if cancelled within 14 days of workshop date. A $75 administrative fee applies to refunds or cancellations made more than 14 days prior to the start of the scheduled workshop. A $25 transfer fee applies to transfers made more than 14 days prior to the start of the scheduled workshop.

In the rare event of date change or course cancellation you will be notified by noon the Tuesday before your scheduled CE. In this case, full refund or transfer of credit without admin fee will be issued

We request that you arrive early for your course. If you need to leave early or step out for a moment, please let Dina know in advance

Client Signature:

Date:

Date

By attending my appointment; I agree that I am not currently experiencing any of these symptoms: Cough - Shortness of breath or difficulty breathing. Fever - Chills- Sore throat-New loss of taste or smell. Please note: Other less common symptoms have been reported, including gastrointestinal symptoms like nausea, vomiting, or diarrhea. I agree that I have not: Tested positive for COVID-19. Knowingly been exposed to someone with COVID-19. Recently traveled to an area with a high infection rate, Been in an area where social distancing was not properly observed, Been to a nursing home. If you have experienced any of the above, please reschedule your appointment at least 14 days from now. Client Signature:

Childcare Form

Cancellation Policy

Lateness Policy