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MUSCLE HAMMER THERAPY WAIVER

23362 Peralta Dr, Suite 1 ~ Laguna Hills, CA 92653
 

  • I understand that Muscle Hammer Therapy is not a medical treatment and does not require a licensed therapist to perform.
  • I understand that Muscle Hammer therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow, and is not intended to treat, cure or prevent any disease.
  • I realize it is my responsibility to inform my therapist when I experience pain or discomfort during the session, so that pressure can be adjusted to my level of comfort. 
  • I understand that Muscle Hammer therapy is an aggressive form of bodywork that may cause bruising, and will not hold my therapist responsible for any pain or discomfort I experience during or after the session.
  • I understand that the services offered are not a substitute for medical care. I understand that my therapist is not a licensed health practitioner and is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.
  • I affirm that I have notified my therapist of all known medical conditions and injuries, and agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so.
  • By signing this release, I hereby waive and release MUSCLE HAMMER and my therapist from any and all liability, past, present, and future relating to Muscle Hammer therapy.
First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

REFERRED BY:

PLEASE LIST ANY SERIOUS HEALTH CONDITIONS AND/OR INJURIES WE SHOULD BE AWARE OF:
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

REFERRED BY:

PLEASE LIST ANY SERIOUS HEALTH CONDITIONS AND/OR INJURIES WE SHOULD BE AWARE OF:
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

REFERRED BY:

PLEASE LIST ANY SERIOUS HEALTH CONDITIONS AND/OR INJURIES WE SHOULD BE AWARE OF:
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

REFERRED BY:

PLEASE LIST ANY SERIOUS HEALTH CONDITIONS AND/OR INJURIES WE SHOULD BE AWARE OF:
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

REFERRED BY:

PLEASE LIST ANY SERIOUS HEALTH CONDITIONS AND/OR INJURIES WE SHOULD BE AWARE OF:
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

REFERRED BY:

PLEASE LIST ANY SERIOUS HEALTH CONDITIONS AND/OR INJURIES WE SHOULD BE AWARE OF:
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

REFERRED BY:

PLEASE LIST ANY SERIOUS HEALTH CONDITIONS AND/OR INJURIES WE SHOULD BE AWARE OF:
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

REFERRED BY:

PLEASE LIST ANY SERIOUS HEALTH CONDITIONS AND/OR INJURIES WE SHOULD BE AWARE OF:
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

REFERRED BY:

PLEASE LIST ANY SERIOUS HEALTH CONDITIONS AND/OR INJURIES WE SHOULD BE AWARE OF:
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

REFERRED BY:

PLEASE LIST ANY SERIOUS HEALTH CONDITIONS AND/OR INJURIES WE SHOULD BE AWARE OF:
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
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.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

REFERRED BY:

PLEASE LIST ANY SERIOUS HEALTH CONDITIONS AND/OR INJURIES WE SHOULD BE AWARE OF:
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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