Client services and chart information are confidential. Written authorization is required from you to release any information.
I hereby apply for processing in Rolfing.
I fully understand the purpose of Rolfing is to balance and align the physical body so that it is supported and maintained by gravity in three-dimensional space. This is done through direct manipulation and education so that greater economy and freedom of body movement is achieved.
I understand Rolfing is not involved with the treatment of disease of any kind, nor does it substitute for medical diagnosis or treatment when such attention is needed.
The Rolfer does not treat, prescribe or diagnose an illness, disease, or any other physical or mental disorder of the person. Nothing said or done by a Rolfer should be misconstrued to be such.
I have read and understood the cancellation policy written on the Client Information Sheet. I agree to notify Ryan Caputi 48 hours in advance of a scheduled appointment if I am unable to keep the said appointment. If I do not notify Caputi 48 hours or more in advance of a scheduled appointment, then I agree to pay him his full fee for the missed appointment.
I understand it is necessary for the Rolfer to touch my body in order to assist in establishing balance and alignment in my body. I give Ryan Caputi my permission and consent to do all those things necessary in helping me to establish balance and alignment, including, but not limited to touching my body. I give Rolf Practitioner, Ryan Caputi full privilege and license to work on my body in such a way as to restore and establish balance and alignment therein.
By signing this release, I hereby waive and release Ryan Caputi, Ryan's Rolfing, and the owner of Kris Shevlin Physical Therapy from any and all liability, past, present, and future relating to massage therapy and bodywork.
I understand that Rolfing therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.
I acknowledge that Rolfing is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.
It is my choice to receive Rolfing as a form of therapy.
I understand that the treatment given is designed to address the care and prevention of myofascial pain and dysfunction.
I also understand that at any time I feel pain or discomfort during the session, I will immediately inform my Rolfer so they adjust.
I have stated my pertinent medical conditions and will update the Rolfer of any changes in my health status.
I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless Peak Rolfing and my Rolfer from any liability whatsoever arising from failure on my part.
By my electronic signature below, I agree to the massage policy and client agreement above.