Consent and Waiver Form
Client Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Relationship
Consent and Waiver
I, undersigned, agree with the following statements:
*
I have disclosed any of my allergies to my healer.
I have disclosed any medications that may effect my massage to my healer.
I have disclosed to my healer IF I am currently pregnant and how far along to my healer.
I have disclosed any recently hospital stays, past surgeries or other serious health issues to my healer.
I have disclosed any recent or past accidents or injuries to my healer,
I understand that my massage will not covered by extended health benefits because this is not an RMT certified massage therapist.
I authorize the use of lotion, oil, and ointments to my body if required.
I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician.
I release River Moon Healing for any responsibility in case of an accident, illness, or injury.
I acknowledge that all information I provided in this form is true and accurate.
Signature of the Client
*
Date Signed
*
-
Month
-
Day
Year
Date
Signature (PDF ONLY)
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Should be Empty: