Consent & Waiver Agreement
I verify that all information is correct and current to the best of my knowledge. I understand that any information provided is for safety purpose s and will be kept strictly confidential, unless I provide written consent. I hereby give my consent to receive treatments and I acknowledge and agree that I am doing so at my own risk. My health and safety with respect to such services are my sole responsibility. My decision to receive services is voluntary, and I know of, understand and assume any and all the risks associated therewith. In exchange for receiving services for myself and on behalf of my heirs, executors, administrators and personal representatives, hereby waive, release, discharge and hold my practitioner harmless from any and all liability for any and all injuries, including damages or claims relating to or resulting from my receipt of the services, now or in the future, foreseen or unforeseen.
Please take a moment to read and initial the following information:
• I will not hold my practitioner responsible for any pain or discomfort I experience before, during or after the session.
• I understand that the services offered today are not a substitute for medical care.
• I understand that my practitioner is not qualified to carry out a medical examination or provide a diagnosis and I agree not to interpret their comments as medical advice.
• I affirm that I have notified my practitioner of all known medical conditions and injuries.
• I agree to inform the practitioner of any changes in my health and medical condition
• I understand that there shall be no liability on the practitioner’s part should I forget to do so.
• I understand that treatment is non-sexual in nature.
• I understand my medical information and treatment notes may be released to other, third party, health practitioners whom I agree for my practitioner to refer me to.
• I agree that my practitioner will need to disclose my personal information, if required to by law.
• By signing this release, I hereby waive and release my practitioner from any and all liability, past, present and future relating to this treatment.
Giving Yourself Space
Signed (typed first and last name acceptable)
By typing my name in this section, I agree that this constitutes an electronic signature and I agree to the above Consent & Waiver Agreement and acknowledge that all information that i provide is true and correct as at the date of signing.
Feel free to ask your practitioner any questions before, during, or after the session. Your practitioner is a skilled professional and will be happy to assist with any queries or concerns.
Send me a copy of my responses.
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