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Your Intake / Consent Form

*To ensure we have the correct information and comply with our requirements of operation, please ensure the information is correct.

All information is treated as private and confidential. This form will be attached to your client information with Uriel's Temple and will be current for 2 years. Please let us know of any changes during that time. If you do not have time fill this in now, it can be done at the studio before your session, please arrive earlier to fill this in. This form only needs to be filled in once in the 2 years. Thank you.

Client Intake Form

Date of birth
Day
Month
Year
State/Territory

Medical History

Are you pregnant?
Yes
No
Are you currently under physician's or specialist's care?
Yes
No
Have you had or using any complimentary therapy treatments?
Yes
No
Are you taking any medications/supplements?
Yes
No
Do you have any recent injuries?
Yes
No
Have you have any surgeries?
Yes
No
Do you have any allergies/ sensitivities?
Yes
No

Reasons and Expectations for Treatment

Thank you, please fill in the following and submit below.

Client Consent & Waiver

I,

Full name:

_____________________________________________________________

verify that all information is correct and current to the best of my knowledge. I understand that any information provided is for safety purposes and will be kept strictly confidential, unless I provide written consent. I hereby give consent to receive treatments and services and 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 treatment and services is voluntary, and I know of, understand and assume any and all risks associated therewith. In exchanges for receiving treatment and services for myself and on behalf of my heirs, executors, administrators and personal representatives, hereby waive, release, discharge and hold my therapist harmless from any and all liability for any and all injuries, including damages and claims relating to or resulting from my receipt of the services, now or in the future, foreseen or unforeseen.

Please read and sign the following information:

  • If I experience pain or discomfort during the session, I will immediately inform my therapist. I will not hold my therapist responsible for any discomfort I expereince before, during, or after the session.

  • I understand the sessions, services offered today are not a substitute for medical care.

  • I understand that my therapist 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 therapist of all known medical conditions and injuries.

  • I agree to inform my therapist of any changes in my health and medical condition. I understand that there shall be no liability on my therapist's part should I forget to do so.

  • I understand that the treatment, session or service is non-sexual in nature.

  • I understand my medical information and treatment notes may be released to other, third-party, health practitioners, who I agree for my therapist to refer me to.

  • I agree that my therapist will need to release my personal information, if required to by law.

  • By signing this release, I hereby waive and release my therapist from any and all liability, past present and future relating to this treatment, session, service.

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