Liability Waiver & Intake Form
Name of Participant
*
First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Afghanistan
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Saint Barthelemy
Saint Helena
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Samoa
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Senegal
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eSwatini
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Date of Birth
*
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Month
-
Day
Year
Date
Gender
*
Female
Male
Other/prefer not to say
E-mail
*
example@example.com
Cellular Number
*
What is your occupation?
*
Do you have any goals for this therapy?
*
Please list any symptoms/complaints, when they began and how often you experience them. Any medical diagnosis that we should be aware of?
Please list any physician-diagnosed injuries, when they occurred and any treatments, surgical procedures or diagnostic work that has been performed:
How often has this interfered with your day-to-day life or work?
Not at all
Moderatley
Almost all the time
Have you been seen by another practitioner for these symptoms?
*
Physician
Physiotherapist
Chiropractor
Massage Therapist
Other
Have you received Fascial Stretch Therapy treatments before?
*
Yes
No
Please list all your current prescriptions, over-the-counter medications and any herbal supplements you are taking:
Is there anything else we should know about?
I ______________ permission to REST to take and use videos/photos of the session for social media
*
give
DO NOT give
REST Liability Waiver - Terms and Conditions
By signing this consent, I agree that I have stated all conditions that I am aware of and the information is true and accurate to the best of my knowledge. I will inform my health care provider, or practitioner if anything changes in my status. I understand that bodywork I receive is for the purpose of increased flexibility, stress reduction and relief from muscular tension, spasm or pain, and to increase circulation. If I experience any pain or discomfort, I will immediately inform my practitioner so that the intensity and/or methods can be adjusted to my comfort level. I understand that utilization of this type of modality can possibly increase soreness and/or pain if I do not communicate honestly and or follow proper precautions following the session. I understand that information exchanged during any session is educational in natureand is intended to help the client become more familiar and conscious of his or her own health status. I understand that an FST Practitioner cannot diagnose illness, disease, or any physical or mental disorders. As such, the practitioner does not prescribe medical treatment or pharmaceuticals, nor do they perform any spinal or skeletal manipulations. It has been made very clear to me that this therapy is not a substitute for medical examinations and/or diagnosis, and I understand that it is my responsibility to consult a physician for any ailments I may have. Given the above, I understand that response to treatment varies on an individual basis and that specific results are not guaranteed. I understand that I am choosing Fascia Stretch Therapy at my own risk. In the event that I become injured either directly or indirectly as a result, in whole or in part, of the aforesaid therapy I hereby hold harmless and release from any liability as well as any officers, directors, or employees of for any condition or result, known or unknown that may arise as a consequence of any treatment I receive. Cancellation Policy - 24 hours notice is required for cancellations, if less than 24 hours notice is given and the appointment is not rebooked, a $50 non-refundable fee will be billed. Multiple cancellations or last minute rebookings may result in termination of services. Late Fees- If full payment is not made after 30 days from the appointment date, late fees will apply. Beginning at $10 and $5 each day there after. Failure to make a payment after 60 days will result in termination of services unless prepayments are discussed and received. I understand that if I arrive late for an appointment, the session will end at the original scheduled time to prevent penalizing another client. However, if the practitioner is late, they will fulfill the scheduled appointment length or offer a reasonable compensation.
Signature
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Signing Date
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