Reflexology Waiver and Consent Form – Crystal Reiki & Healing by Sheena

If you checked any disorders or diseases above, please use the next few lines to explain. (Example: dates, areas of disorder/disease, type, symptoms of concern. Please be specific.)

Is there anything else about your health history that you think would be useful for the Reflexology practitioner to know to plan a safe and effective session for you? *

Have you ever received Reflexology therapy before? *

What are your goals for this session? *

Do you have difficulty lying on your front, back, or side? *

Release. I recognize that there are certain inherent risks associated with the above-described treatment and I assume full responsibility for personal injury to myself. In exchange for such treatment, I hereby fully release and forever discharge Crystal Reiki & Healing by Sheena (including its officers, members, owners, employees and agents) from any and all damages, costs, expenses, liabilities, causes of action, claims and demands, of whatever character, in law or in equity, whether known or unknown, direct or indirect, asserted or unasserted, and whether or not on account of myself, Crystal Reiki & Healing by Sheena. or other third parties, or in any way arising out of the above described treatment I have requested Sheena Apostolopoulos to perform. It is the intention of the parties that this agreement binds all parties whose claims may arise out of or relate to the treatment or services provided by Crystal Reiki & Healing by Sheena including any spouse or heirs of the client/patient and any children, whether born or unborn. Any legal or equitable claim that may arise from participation in the treatment shall be resolved under Pennsylvania law. I agree to indemnify, hold harmless and defend Crystal Reiki & Healing by Sheena (including its officers, members, owners, employees and agents) against all third-party claims, causes of action, damages, judgments, costs or expenses, including attorneys’ fees and other litigation costs, which may in any way arise from the above described treatment I have requested Crystal Reiki & Healing by Sheena to perform. By signing this agreement I confirm that I am over the age of 18, I understand that the Emslim Neo procedure is permanent, that such procedure has possible adverse consequences and that the procedure is for cosmetic purposes only. I certify that I have read the above paragraphs; had the procedure and risks explained to me, fully understand this consent and procedure form and herby consent to the indicated procedure(s). This means that I accept full responsibility for these and/or any other complications which may arise or result during or following the Emslim Neo, Coolsculpting, RF, and any other noninvasive procedure which is to be performed at my request according to this agreement and I herby agree to wave any arbitration of any malpractice claim. I further understand that by signing this agreement, I surrender certain legal rights.

I have read, understand, & Consent

First Name

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Signature

Reflexology/Energy Work Waiver and Consent Form