Services Liability Waiver & Informed Consent
Review the non-medical wellness consent and liability terms, complete your health disclosures, and sign before receiving services.
Client Information & Emergency Contact
Client full legal name
*
First Name
Middle Name
Last Name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email address
*
example@example.com
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency contact name
*
First Name
Middle Name
Last Name
Emergency contact phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Health Disclosure & Eligibility
Do you have any health conditions relevant to receiving wellness services?
*
Yes
No
Not sure
Are you currently pregnant, or is pregnancy possible?
*
Yes
No
Prefer not to say
Please list any current medications, allergies, or sensitivities
Do you have any implanted or electronic devices?
Pacemaker
Implantable defibrillator
Hearing aid
Joint replacement
Other
Please describe any recent surgeries, injuries, or physician-imposed restrictions
By continuing, I confirm that the health information I provide is accurate and complete, and I will update it if my circumstances change. I understand that medical clearance should be obtained when appropriate.
Consent, Liability Waiver & Signature
Optional Consent for Non-Diagnostic Wellness Education and Recommendations
*
I consent to receive non-diagnostic wellness education and recommendations
I do not consent
Acknowledgment Before Signature
*
I have read and understand this waiver and informed consent, have had the opportunity to ask questions, and voluntarily agree.
Electronic Signature
*
Sign and Consent
Sign and Consent
Should be Empty: