Loading...

Mountain Somatics Consent Waiver

I,

hereby agree that by signing this document, I consent to waive certain legal rights, including the right to sue the following party, and facilities from any physical, material, tangible or intangible loss or  damage including any  virius that may be present thereafter that  may  happen to me during my participation in any of the Structual Integration sessions. 

Mountain Somatics Structral Integration

Ticia Sheets, CMT Certified Rolf SI Practioner

Po Box 1015

Victor, ID 83455

307-413-8080

I am Voluntarily receiving Structural Integration Services from the SI Practioner  Ticia Sheets


 

April 28, 2024

First Client Name

First Name*

Middle Name

Last Name*

Phone*
First Client Date of Birth*
First Client Information
Have you experienced a Rolf SI Bodywork session?*
No
Yes

If yes, explain.

Please list areas of discomfort or pain
Are you currently under the care of a Physician, Chiropractor, Physical Therapist?*
No
Yes

If you answered yes please explain

Please list all medical conditions

Please list all medications

Please list all injures and surgeries
Have you recently traveled out of the area or country?*
No
Yes

If yes please explain
Have you experienced coughing, Fever, Stomachache or other symptoms of Covid-19 in the last 14 days.*
No
Yes

If yes please explain
First Client Signature*
Second Client Name

First Name*

Middle Name

Last Name*
Second Client Date of Birth*
Second Client Information
Have you experienced a Rolf SI Bodywork session?*
No
Yes

If yes, explain.

Please list areas of discomfort or pain
Are you currently under the care of a Physician, Chiropractor, Physical Therapist?*
No
Yes

If you answered yes please explain

Please list all medical conditions

Please list all medications

Please list all injures and surgeries
Have you recently traveled out of the area or country?*
No
Yes

If yes please explain
Have you experienced coughing, Fever, Stomachache or other symptoms of Covid-19 in the last 14 days.*
No
Yes

If yes please explain
Third Client Name

First Name*

Middle Name

Last Name*
Third Client Date of Birth*
Third Client Information
Have you experienced a Rolf SI Bodywork session?*
No
Yes

If yes, explain.

Please list areas of discomfort or pain
Are you currently under the care of a Physician, Chiropractor, Physical Therapist?*
No
Yes

If you answered yes please explain

Please list all medical conditions

Please list all medications

Please list all injures and surgeries
Have you recently traveled out of the area or country?*
No
Yes

If yes please explain
Have you experienced coughing, Fever, Stomachache or other symptoms of Covid-19 in the last 14 days.*
No
Yes

If yes please explain
Fourth Client Name

First Name*

Middle Name

Last Name*
Fourth Client Date of Birth*
Fourth Client Information
Have you experienced a Rolf SI Bodywork session?*
No
Yes

If yes, explain.

Please list areas of discomfort or pain
Are you currently under the care of a Physician, Chiropractor, Physical Therapist?*
No
Yes

If you answered yes please explain

Please list all medical conditions

Please list all medications

Please list all injures and surgeries
Have you recently traveled out of the area or country?*
No
Yes

If yes please explain
Have you experienced coughing, Fever, Stomachache or other symptoms of Covid-19 in the last 14 days.*
No
Yes

If yes please explain
Fifth Client Name

First Name*

Middle Name

Last Name*
Fifth Client Date of Birth*
Fifth Client Information
Have you experienced a Rolf SI Bodywork session?*
No
Yes

If yes, explain.

Please list areas of discomfort or pain
Are you currently under the care of a Physician, Chiropractor, Physical Therapist?*
No
Yes

If you answered yes please explain

Please list all medical conditions

Please list all medications

Please list all injures and surgeries
Have you recently traveled out of the area or country?*
No
Yes

If yes please explain
Have you experienced coughing, Fever, Stomachache or other symptoms of Covid-19 in the last 14 days.*
No
Yes

If yes please explain
Sixth Client Name

First Name*

Middle Name

Last Name*
Sixth Client Date of Birth*
Sixth Client Information
Have you experienced a Rolf SI Bodywork session?*
No
Yes

If yes, explain.

Please list areas of discomfort or pain
Are you currently under the care of a Physician, Chiropractor, Physical Therapist?*
No
Yes

If you answered yes please explain

Please list all medical conditions

Please list all medications

Please list all injures and surgeries
Have you recently traveled out of the area or country?*
No
Yes

If yes please explain
Have you experienced coughing, Fever, Stomachache or other symptoms of Covid-19 in the last 14 days.*
No
Yes

If yes please explain
Seventh Client Name

First Name*

Middle Name

Last Name*
Seventh Client Date of Birth*
Seventh Client Information
Have you experienced a Rolf SI Bodywork session?*
No
Yes

If yes, explain.

Please list areas of discomfort or pain
Are you currently under the care of a Physician, Chiropractor, Physical Therapist?*
No
Yes

If you answered yes please explain

Please list all medical conditions

Please list all medications

Please list all injures and surgeries
Have you recently traveled out of the area or country?*
No
Yes

If yes please explain
Have you experienced coughing, Fever, Stomachache or other symptoms of Covid-19 in the last 14 days.*
No
Yes

If yes please explain
Eighth Client Name

First Name*

Middle Name

Last Name*
Eighth Client Date of Birth*
Eighth Client Information
Have you experienced a Rolf SI Bodywork session?*
No
Yes

If yes, explain.

Please list areas of discomfort or pain
Are you currently under the care of a Physician, Chiropractor, Physical Therapist?*
No
Yes

If you answered yes please explain

Please list all medical conditions

Please list all medications

Please list all injures and surgeries
Have you recently traveled out of the area or country?*
No
Yes

If yes please explain
Have you experienced coughing, Fever, Stomachache or other symptoms of Covid-19 in the last 14 days.*
No
Yes

If yes please explain
Ninth Client Name

First Name*

Middle Name

Last Name*
Ninth Client Date of Birth*
Ninth Client Information
Have you experienced a Rolf SI Bodywork session?*
No
Yes

If yes, explain.

Please list areas of discomfort or pain
Are you currently under the care of a Physician, Chiropractor, Physical Therapist?*
No
Yes

If you answered yes please explain

Please list all medical conditions

Please list all medications

Please list all injures and surgeries
Have you recently traveled out of the area or country?*
No
Yes

If yes please explain
Have you experienced coughing, Fever, Stomachache or other symptoms of Covid-19 in the last 14 days.*
No
Yes

If yes please explain
Tenth Client Name

First Name*

Middle Name

Last Name*
Tenth Client Date of Birth*
Tenth Client Information
Have you experienced a Rolf SI Bodywork session?*
No
Yes

If yes, explain.

Please list areas of discomfort or pain
Are you currently under the care of a Physician, Chiropractor, Physical Therapist?*
No
Yes

If you answered yes please explain

Please list all medical conditions

Please list all medications

Please list all injures and surgeries
Have you recently traveled out of the area or country?*
No
Yes

If yes please explain
Have you experienced coughing, Fever, Stomachache or other symptoms of Covid-19 in the last 14 days.*
No
Yes

If yes please explain
Client Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
I understand that the bodywork I receive is by my choice, I will communicate with my therapist if I experience any pain or discomfort during these sessions. I also understand that bodywork should not be construed as a substitute for medical examination or diagnosis. I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part. I also understand I will cancel my appointment within 24 hrs or I will be charged for the missed session.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Have you experienced a Rolf SI Bodywork session?*
No
Yes

If yes, explain.

Please list areas of discomfort or pain
Are you currently under the care of a Physician, Chiropractor, Physical Therapist?*
No
Yes

If you answered yes please explain

Please list all medical conditions

Please list all medications

Please list all injures and surgeries
Have you recently traveled out of the area or country?*
No
Yes

If yes please explain
Have you experienced coughing, Fever, Stomachache or other symptoms of Covid-19 in the last 14 days.*
No
Yes

If yes please explain
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!