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HEALTH QUESTIONNAIRE

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Full Name
Age
Nationality
Occupation
Address
Do you have any injuries or special conditions?
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Are you taking any medications or supplements?
What areas would you like to focus on today?

Are there any pre-existing issues that the therapist needs to be aware of?

*Therapy during pregnancy is not advised.

*You should wait at least 45 minutes after eating before treatment.

*Please advise what pressure you would like during the treatment or if you feel any pain.

*Do not consume drugs or alcohol before treatment.

RELEASE

I am voluntarily participating in the service/treatment with the full knowledge and understanding of the risks and that my participation may cause injury. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the service/treatment. I certify that I am physically fit and I have no medical condition to prevent my participation.
I agree to idemnify, release and forever discharge Ocean Bloom from all liabilities, claims, actions, damages, costs or expenses, of any nature arising out of or in any way connected with my participation in the service/treatment.
I have read and fully understand the information provided.

Full Name

THANK YOU FOR SUBMITTING!

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