INFORMED CONSENT FOR PARTICIPATION, Ashiatsu Practice Body Floor and Ashiatsu Bar Complimentary Student Clinic: I understand this is a student clinic complimentary session and the "Activity Provider(s)" BodyWork Health Practitioner(s) Novum LL Bliss LLC / Aum Body Bliss LLC c/o Novum LaLuna LMT., may be following along with a video and listening to the instructor but will be able to hear and communicate with me. I understand the "Activity Provider(s)" BodyWork Health Practitioner(s) Novum LL Bliss LLC / Aum Body Bliss LLC c/o Novum LaLuna LMT., will be focused on the practice but will be checking in with me periodically about how the Massage feels, and while technique (body mechanics and breath), flow of sequences, and foot palpations are the focus during student practice clinic, the "Activity Provider(s)" BodyWork Health Practitioner(s) Novum LL Bliss LLC / Aum Body Bliss LLC c/o Novum LaLuna LMT., will check in about pressure more than normal due to the deep tissue nature of Ashiatsu BodyWork. If the pressure is too much and is uncomfortable at any time, I will let the "Activity Provider(s)" BodyWork Health Practitioner(s) Novum LL Bliss LLC / Aum Body Bliss LLC c/o Novum LaLuna LMT., know of any adjustments needed. I understand that all feedback is always useful.
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SELECT
YES, I agree to the Ashiatsu Practice Body Floor and Ashiatsu Bar Complimentary Student Clinic Informed Consent For Participation Terms.
NO, I do not agree to the Ashiatsu Practice Body Floor and Ashiatsu Bar Complimentary Student Clinic Informed Consent For Participation Terms.
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First Name
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Describe Level of Discomfort from a scale of 1-10, 10 being the most severe. Describe Type, Pain or Stress; Stress Tension or Stress Tightness (Tension Stress comes from tensile stress/strain, such as pulling a rope. Tension is vectoral/rectilinear in nature. Tightness Stress typically refers to contraction/shortening/shrinking/reduction of a range of motion on a designated plane, field, or given dimension). Do you feel Pain or Stress? If Stress, what type? How often? What activity(ies) make you notice the area(s) most? Is the area(s) anterior or posterior (front or back)? Are symptom(s) of discomfort sharp or radiating?
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Please list any RECENT skeletal or muscular injury(ies)/accident(s):
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Please list any PREVIOUS skeletal or muscular injury(ies)/accident(s):
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Please list any present health, wellness, pain concern(s) or information(s):
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Are you on any prescribed medication(s) and/or over the counter drug(s) and/or supplement(s)?
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SELECT
Yes
No
If YES, please list over the counter or prescribed medication(s) and/or supplement(s):
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INFORMED CONSENT FOR PARTICIPATION, "Complimentary Student Clinic Promotional Offering(s) Valid For A Limited Time Upon Approval Only" Ashiatsu Floor and Ashiatsu Bar Practice Body: By typing my name below and submitting this "Complimentary Student Clinic Promotional Offering(s) Valid For A Limited Time Upon Approval Only"Ashiatsu Floor and Ashiatsu Bar Practice Body Form, I certify and understand it is an extension of the Initial Clinic Client Consultation Form and Activity Waiver Legal Release Form, and any information collected by the Initial Clinic Client Consultation Form and Activity Waiver Legal Release Form applies to this "Complimentary Student Clinic Promotional Offering(s) Valid For A Limited Time Upon Approval Only" Ashiatsu Floor and Ashiatsu Bar Practice Body Form. By typing my name below and submitting this "Complimentary Student Clinic Promotional Offering(s) Valid For A Limited Time Upon Approval Only" Ashiatsu Floor and Ashiatsu Bar Practice Body Form, I certify and understand it is a legitimate record of my written signature, agreement and approval, and all stated information is accurate, true to my knowledge, confidential, and will not be shared without my express written consent unless such information is required by the Activity Waiver Legal Release Form Term(s). I understand the Activity Waiver Legal Release Form and the Initial Clinic Client Consultation Form is a requirement with this "Complimentary Student Clinic Promotional Offering(s) Valid For A Limited Time Upon Approval Only" Ashiatsu Floor and Ashiatsu Bar Practice Body Form to receive valuable quality service(s), activity(ies), content(s), good(s) and offering(s). I understand all information stated serve(s) to provide professional care on a professional level for complementary alternative medicine in manual body corrective work for soft tissue and muscular therapy and valuable quality service(s), activity(ies), content(s), good(s), event(s) and offering(s) that are in accordance with health and safety regulation(s) within reason and to the best of the "Activity Provider(s)" BodyWork Health Practitioner(s) Novum LL Bliss LLC / Aum Body Bliss LLC c/o Novum LaLuna LMT., ability(ies), that is fair or reasonable, and not extreme for all party(ies) involved. I understand that if the information I have given on this form has changed and need(s) to be updated, I will immediately notify the "Activity Provider(s)" BodyWork Health Practitioner(s) Novum LL Bliss LLC / Aum Body Bliss LLC c/o Novum LaLuna LMT. I understand proper, respectful, healthy hygiene and etiquette is a must at all times and any inappropriate misconduct may be reason to end service(s). I understand the "Activity Provider(s)" BodyWork Health Practitioner(s) Novum LL Bliss LLC / Aum Body Bliss LLC c/o Novum LaLuna LMT., does not diagnose or treat a health problem(s) or disease(s), and those seeking personal medical advice should consult with a licensed physician; a recognized doctor or other qualified health provider regarding a medical condition(s). I understand all content on Novum LL Bliss LLC / Aum Body Bliss LLC c/o Novum LaLuna LMT., is educational, for informational purpose(s) only and does not constitute providing medical advice or medical service(s). I understand my Right of Refusal and the Right of Refusal of the "Activity Provider(s)" BodyWork Health Practitioner(s) Novum LL Bliss LLC / Aum Body Bliss LLC c/o Novum LaLuna LMT. I understand tardiness shortens service(s), activity(ies), offering(s) times. I understand I have a 24 hour grace period to provide notice for any cancellation(s), no-show(s), rescheduling etc., after which time I will be held liable for all incidence(s) of inconvenience(s) which may result in termination or extinguishment of further continuation of rendered service(s). I agree to all term(s) and condition(s).
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