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Informed, Voluntary Consent & Release of Liability

I, the undersigned, have read, understand, and completed, to the best of my knowledge, this Intake & Waiver Form. I confirm that I read, write, and understand English well. I have alerted the Therapist / Practitioner of all my applicable conditions / medications up-to-date.


I understand and agree that it is my responsibility to keep the Therapist / Practitioner up-to-date on any changes in my health history. I release the Therapist / Practitioner from any and all liability from problems arising in the session(s) as a result of health history omission. 

In the event that I become injured, either directly or indirectly as a result, in whole or in part, of the aforesaid session(s), I hereby hold harmless and indemnify the Therapist / Practitioner, their principals and agents from all claims and liability whatsoever. 


I understand that I may ask questions about the information being requested and my session(s) at any time, that all session(s) will be discussed, planned with the Therapist / Practitioner and will require my informed, voluntary consent and that I may withdraw my consent at any time by verbalizing this to my Therapist / Practitioner and the session(s) will be stopped. I understand that all client information is confidential and written authorization will be obtained prior to release of information. 


I understand the general benefits of the session(s) as well as the utilization of any other tools/products, possible contraindications and precautions, the assessment and plan, and that it is my responsibility to communicate any discomfort during any session(s). 


I understand that these session(s) and associated modalities are not a substitute for medical treatment or medications and that it is recommended that I work with my Primary Caregiver for any condition(s) I may have. I understand that a Therapist / Practitioner does not diagnose illness or disease and does not prescribe medications. I understand there are alternate treatment options (i.e. chiropractic, physiotherapy, acupuncture, rest, etc.).

I understand that, by agreeing to this policy, I provide my informed, voluntary consent to receive the requested session(s) at my own risk.


I have reviewed this policy, I understand it and I agree to abide by its terms.

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