FIRST TIME / LIABILITY WAIVER

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"All the information provided here will be exclusively for use during our sessions and will be kept strictly confidential, in accordance with a strict code of privacy ethics."
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Name* This field is required.
First Name
Last Name
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Email
example@example.com
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Phone Number
Please enter a valid phone number.
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Emergency contact* This field is required.
Please enter your phone
Please enter the Name & Last Name
6
I understand and agree that I must make the payment in advance corresponding to the sessions that I will attend* This field is required.
YESNO
7
Private sessions and group bookings can be rescheduled without penalty with at least 48 hours advance notice. If less than 48 hours notice is given, the session will not be refundable or transferred.* This field is required.
ACCEPTDECLINE
8
Do you have any medical, mental, or emotional conditions or challenges?* This field is required.If yes, please list all of them.
Please Select
Please Select
Yes
No
Choose your answer
9
Are you struggling with any addiction right now?* This field is required.If yes, please list all of them.
Please Select
Please Select
Yes
No
Choose your answer
10
Are you currently taking any medicine?* This field is required.If yes, please list all of them.
Please Select
Please Select
Yes
No
Choose your answer
11
Have you had a recent surgery?* This field is required.If yes, please explain what and how long ago?
Please Select
Please Select
Yes
No
Choose your answer
12
Are you currently pregnant?* This field is required.If yes, how far along? Any high risk factors?
Please Select
Please Select
Yes
No
Choose your answer
13
Are you allergic to any odor, lotion and/or chemical?* This field is required.If yes, please list all of them.
Please Select
Please Select
Yes
No
Choose your answer
14
Session start and end times are fixed. If you arrive late or need to step away in the middle of the session, the facilitator will still end at the scheduled time* This field is required.
ACCEPTED DECLINED
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I understand that my facilitator is not a clinician and cannot treat, diagnose, or cure any disease, illness, or injury. In all cases, you should join sessions with approval from a trusted medical professional and should always follow your doctor’s advice.* This field is required.
ACCEPTED DECLINED
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You take full responsibility for your own health and any illness or injury that may occur. You cannot and will not hold instructors or any employers or affiliates responsible in the case of accident or illness during practice* This field is required.
ACCEPTED DECLINED
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I am providing my contact information for session registration, updates, marketing, and communication. I can opt-out and cancel/remove my complete data at any time by contacting my facilitator
ACCEPTED DECLINED
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In the event of receiving a holistic wellness session, you agree and understand that this experience is not a state-licensed therapeutic massage in Indiana, but rather an integral relaxation process that combines energetic, sound, and sensory techniques to promote your overall well-being
ACCEPTED DECLINE
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I authorize the use of photographs and/or videos taken during any of my sessions, only for promotional purposes of Andy Vald Holistic
YESNO
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I have read and understand the terms and conditions of sessions as outlined previously* This field is required.
ACCEPTDECLINE
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Are you willing to update this questionnaire if there have been any changes in your information since the last session?* This field is required.
ACCEPTDECLINE
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Name and Last Name* This field is required.Accepting the form
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