V-Steam Client Intake Form

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Check all that apply
EndometriosisPIDSTIChildbirthMenopauseIUDPainMiscarriageInfertilityPolycystic OvariesBreastfeedingPMSProlapsed UterusBacterial VaginosisBreast ImplantsVaginal SurgeryBreast ImplantsVaginal Piercing

Please indicate any mental discomfort that you are experiencing
AnxietyAngerCompulsiveMemory TroubleDepressedUnfocusedHyperactiveConfusedHeadacheIndecisiveLack of EnergyExcess StressConsistently Frustrated / Annoyed

Woman should not do v-steam, if they are experiencing : extremely heavy menstrual cycles, do not do during your period, if you have a vaginal infection, open wounds, sores, or blisters, do not do if you are pregnant or think you may be pregnant. If you have genital piercings, take them out, the heat will cause the piercing to burn you.

I HAVE CAREFULLY READ AND REVIEWED THIS ACKNOWLEDGMENT AND WAIVER OF LIABILITY, AND I FULLY UNDERSTAND ALL OF ITS TERMS AND CONDITIONS. I RECOGNIZE AND ACCEPT ALL RISKS AND LIMITATIONS INVOLVED IN SEEKING ADVICE AND TREATMENT THERAPIES FROM BODY IN MOTION HEALTH & FITNESS, ITS ASSOCIATES, EMPLOYEES, AGENTS AND REPRESENTATIVES THEREOF. I HAVE NOT RELIED UPON ANY OTHER PROMISES, AGREEMENTS OR REPRESENTATIONS BY BODY IN MOTION, OR ANY ASSOCIATES, EMPLOYEES, AGENTS OR REPRESENTATIVES THEREOF CONCERNING THE TREATMENT PROVIDED OR THE TERMS OF THIS ACKNOWLEDGEMENT AND WAIVER OF LIABILITY. I HAVE BEEN ENCOURAGED BY BODY IN MOTION TO SEEK THE ADIVE OF LEGAL COUNSEL CONCERNING THIS ACKNOWLEDGEMENT AND WAIVER OF LIABILITY; AND I EXECUTE AND DELIVER THIS ACKNOWLEDGEMENT AND WAIVER OF LIABILITY FREELY AND VOLUNTARILY AND WITHOUT DURESS OR COERCION AND WITH FULL KNOWLEDGE OF THE REPRESENTATIONS CONTAINED HEREIN AND THE RIGHTS RELINQUISHED, SURRENDERED, RELEASED AND DISCHARGED HEREUNDER. UNDERSTOOD, ACCEPTED AND AGREED.

I UNDERSTAND THAT PAYMENT IS DUE IN FULL AT THE TIME OF MAKING AN APPOINTMENT FOR TREATMENT AT BODY IN MOTION FITNESS STUDIO. I AGREE TO GIVE AT LEAST 48 HOURS NOTICE OF CANCELLATION OF APPOINTMENT OTHERWISE I WILL LOSE MY PAID TREATMENT FEE IN FULL AND BE REQUIRED TO PAY AGAIN FOR ANY NEW APPOINTMENT. I UNDERSTAND THE TREATMENT HERE IS NOT A REPLACEMENT FOR MEDICAL CARE. I UNDERSTAND THE THERAPIST/PRACTITIONER DOES NOT DIAGNOSE MEDICAL ILLNESS, DISEASE OR ANY OTHER PHYSICAL OR MENTAL CONDITIONS (UNLESS SPECIFIED UNDER HIS/HER PROFESSIONAL SCOPE OF PRACTICE) AS SUCH, THE THERAPIST/PRACTITIONER DOES NOT PRESCRIBE MEDICAL TREATMENT OF PHARMACEUTICALS, NOR DOES HE/SHE PERFORM ANY SPINAL MANIPULATIONS (UNLESS SPECIFIED UNDER HIS/HER PROFESSIONAL SCOPE OF PRACTICE) I UNDERSTAND THAT THE TREATMENT IS NOT A SUBSTITUTE OF MEDICAL TREATMENTS AND/OR DIAGNOSIS AND IT IS RECOMMENDED THAT I SEE A QUALIFIED PROFESSIONAL FOR ANY PHYSICAL OR MENTAL CONDITIONS THAT I MAY HAVE. I HAVE STATED ALL MY KNOW CONDITIONS AND TAKE IT UPON MYSELF TO KEEP THE THERAPIST/PRACTITIONER UPDATED ON MY HEALTH.

I GIVE MY PERMISSION FOR MY THERAPIST/PRACTITIONER TO TAKE NOTES ABOUT ME, INCLUDING HEALTH HISTORY, MEDICAL, AND/OR PERSONAL INFORMATION I CHOOSE TO DISCLOSE TO HIM/HER. I ALSO UNDERSTAND THAT THIS INFORMATION WILL ANONYMOUSLY BE USED FOR THE B.I.M HEALTH & FITNESS STUDIO, LLC. FOR STATISTICAL PURPOSES, AND THAT MY PRACTITIONER MAY USE THIS INFORMATION TO PROVIDE ME WITH A SUMMARY FOR MY OWN PERSONAL USE.