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Rolfmesi Structural Integration

Ivette C. Pinela

Master Practitioner

LIC 18663

 

 

I fully understand the purpose of Rolfing/Structural Integration 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 of body-movement is achieved. I understand Rolfing/Structural Integration 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 Practitioner 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 Practitioner should be misconstrued to be such. I understand it is necessary for the Practitioner to touch my body in order to assist me in establishing balance and alignment of my body.

I give Ivette C. Pinela LMT,SI,BF my permission and consent to do all those things necessary in helping me establish balance and alignment, including but not limited to touching my body. I give Ivette C. Pinela LMT,SI,BF full privilege and license to work on my body in such a way as to restore and establish balance and alignment therein. Furthermore, I understand that any relief of physical or emotional symptoms is coincidental in the organization of the total human being and is not the goal of Rolfing/Structural Integration.

IN CASE OF CANCELLATION I agree to give 24 hours advance notice of scheduled session, or to assume responsibility for payment of the full fee. By signing below, I acknowledge that I have read and understood all parts of this waiver, that I have had the opportunity to ask any questions regarding the services provided. 

 

First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
Select Gender
First Participant's Date of Birth*
Date of Birth
Information

What is your occupation? *

What Position Do you sleep in? *

How Do you workout and how often do you workout?

What areas of your body are you currently having issues or pain with? How long have you been in pain? *

Have you experienced Rolfing/Structural Integration before? if yes? Please List What experience do you have with the work(Ten-series,Advanced 3 series, or Advanced 5 series *

What is your Medical History? Please List any Broken Bones, Surgeries, or Car/Motorcycle accidents? (yes,liposuction and cosmetic surgeries included) *Please include the year they occurred* *

Do You Have Dentures/Braces, IUD, or Prescription Eyewear?*** It is Important to to Know that Structural Integration can change the Fitting of things made for your body*** *

Are you currently on any Medications? if yes, please list
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Information

What is your occupation? *

What Position Do you sleep in? *

How Do you workout and how often do you workout?

What areas of your body are you currently having issues or pain with? How long have you been in pain? *

Have you experienced Rolfing/Structural Integration before? if yes? Please List What experience do you have with the work(Ten-series,Advanced 3 series, or Advanced 5 series *

What is your Medical History? Please List any Broken Bones, Surgeries, or Car/Motorcycle accidents? (yes,liposuction and cosmetic surgeries included) *Please include the year they occurred* *

Do You Have Dentures/Braces, IUD, or Prescription Eyewear?*** It is Important to to Know that Structural Integration can change the Fitting of things made for your body*** *

Are you currently on any Medications? if yes, please list
Third Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Information

What is your occupation? *

What Position Do you sleep in? *

How Do you workout and how often do you workout?

What areas of your body are you currently having issues or pain with? How long have you been in pain? *

Have you experienced Rolfing/Structural Integration before? if yes? Please List What experience do you have with the work(Ten-series,Advanced 3 series, or Advanced 5 series *

What is your Medical History? Please List any Broken Bones, Surgeries, or Car/Motorcycle accidents? (yes,liposuction and cosmetic surgeries included) *Please include the year they occurred* *

Do You Have Dentures/Braces, IUD, or Prescription Eyewear?*** It is Important to to Know that Structural Integration can change the Fitting of things made for your body*** *

Are you currently on any Medications? if yes, please list
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Information

What is your occupation? *

What Position Do you sleep in? *

How Do you workout and how often do you workout?

What areas of your body are you currently having issues or pain with? How long have you been in pain? *

Have you experienced Rolfing/Structural Integration before? if yes? Please List What experience do you have with the work(Ten-series,Advanced 3 series, or Advanced 5 series *

What is your Medical History? Please List any Broken Bones, Surgeries, or Car/Motorcycle accidents? (yes,liposuction and cosmetic surgeries included) *Please include the year they occurred* *

Do You Have Dentures/Braces, IUD, or Prescription Eyewear?*** It is Important to to Know that Structural Integration can change the Fitting of things made for your body*** *

Are you currently on any Medications? if yes, please list
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Information

What is your occupation? *

What Position Do you sleep in? *

How Do you workout and how often do you workout?

What areas of your body are you currently having issues or pain with? How long have you been in pain? *

Have you experienced Rolfing/Structural Integration before? if yes? Please List What experience do you have with the work(Ten-series,Advanced 3 series, or Advanced 5 series *

What is your Medical History? Please List any Broken Bones, Surgeries, or Car/Motorcycle accidents? (yes,liposuction and cosmetic surgeries included) *Please include the year they occurred* *

Do You Have Dentures/Braces, IUD, or Prescription Eyewear?*** It is Important to to Know that Structural Integration can change the Fitting of things made for your body*** *

Are you currently on any Medications? if yes, please list
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Information

What is your occupation? *

What Position Do you sleep in? *

How Do you workout and how often do you workout?

What areas of your body are you currently having issues or pain with? How long have you been in pain? *

Have you experienced Rolfing/Structural Integration before? if yes? Please List What experience do you have with the work(Ten-series,Advanced 3 series, or Advanced 5 series *

What is your Medical History? Please List any Broken Bones, Surgeries, or Car/Motorcycle accidents? (yes,liposuction and cosmetic surgeries included) *Please include the year they occurred* *

Do You Have Dentures/Braces, IUD, or Prescription Eyewear?*** It is Important to to Know that Structural Integration can change the Fitting of things made for your body*** *

Are you currently on any Medications? if yes, please list
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Information

What is your occupation? *

What Position Do you sleep in? *

How Do you workout and how often do you workout?

What areas of your body are you currently having issues or pain with? How long have you been in pain? *

Have you experienced Rolfing/Structural Integration before? if yes? Please List What experience do you have with the work(Ten-series,Advanced 3 series, or Advanced 5 series *

What is your Medical History? Please List any Broken Bones, Surgeries, or Car/Motorcycle accidents? (yes,liposuction and cosmetic surgeries included) *Please include the year they occurred* *

Do You Have Dentures/Braces, IUD, or Prescription Eyewear?*** It is Important to to Know that Structural Integration can change the Fitting of things made for your body*** *

Are you currently on any Medications? if yes, please list
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Information

What is your occupation? *

What Position Do you sleep in? *

How Do you workout and how often do you workout?

What areas of your body are you currently having issues or pain with? How long have you been in pain? *

Have you experienced Rolfing/Structural Integration before? if yes? Please List What experience do you have with the work(Ten-series,Advanced 3 series, or Advanced 5 series *

What is your Medical History? Please List any Broken Bones, Surgeries, or Car/Motorcycle accidents? (yes,liposuction and cosmetic surgeries included) *Please include the year they occurred* *

Do You Have Dentures/Braces, IUD, or Prescription Eyewear?*** It is Important to to Know that Structural Integration can change the Fitting of things made for your body*** *

Are you currently on any Medications? if yes, please list
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Information

What is your occupation? *

What Position Do you sleep in? *

How Do you workout and how often do you workout?

What areas of your body are you currently having issues or pain with? How long have you been in pain? *

Have you experienced Rolfing/Structural Integration before? if yes? Please List What experience do you have with the work(Ten-series,Advanced 3 series, or Advanced 5 series *

What is your Medical History? Please List any Broken Bones, Surgeries, or Car/Motorcycle accidents? (yes,liposuction and cosmetic surgeries included) *Please include the year they occurred* *

Do You Have Dentures/Braces, IUD, or Prescription Eyewear?*** It is Important to to Know that Structural Integration can change the Fitting of things made for your body*** *

Are you currently on any Medications? if yes, please list
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Information

What is your occupation? *

What Position Do you sleep in? *

How Do you workout and how often do you workout?

What areas of your body are you currently having issues or pain with? How long have you been in pain? *

Have you experienced Rolfing/Structural Integration before? if yes? Please List What experience do you have with the work(Ten-series,Advanced 3 series, or Advanced 5 series *

What is your Medical History? Please List any Broken Bones, Surgeries, or Car/Motorcycle accidents? (yes,liposuction and cosmetic surgeries included) *Please include the year they occurred* *

Do You Have Dentures/Braces, IUD, or Prescription Eyewear?*** It is Important to to Know that Structural Integration can change the Fitting of things made for your body*** *

Are you currently on any Medications? if yes, please list
Participant's 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*
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*
Select Gender
Parent or Guardian's Date of Birth*
Date of Birth
Information

What is your occupation? *

What Position Do you sleep in? *

How Do you workout and how often do you workout?

What areas of your body are you currently having issues or pain with? How long have you been in pain? *

Have you experienced Rolfing/Structural Integration before? if yes? Please List What experience do you have with the work(Ten-series,Advanced 3 series, or Advanced 5 series *

What is your Medical History? Please List any Broken Bones, Surgeries, or Car/Motorcycle accidents? (yes,liposuction and cosmetic surgeries included) *Please include the year they occurred* *

Do You Have Dentures/Braces, IUD, or Prescription Eyewear?*** It is Important to to Know that Structural Integration can change the Fitting of things made for your body*** *

Are you currently on any Medications? if yes, please list
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.


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