By signing below, you agree to the following:
I have completed this form to the best of my ability and knowledge and agree to inform my practitioner of any changes to the information listed on all pages of this intake form. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform my practitioner of any discomfort I may experience during the requested treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my practitioner and the company in which I am voluntarily seeking services from for any injury or damages incurred due to any misrepresentation of my health history.