Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, massage/body work may be contraindicated. A referral from your primary care provider may be required prior to services provided.
We require 24 hours’ notice for cancellations. In the case of late cancellations you will be charged for the appointment.
I understand that the services provided are for the basic purpose of relaxation, relief of muscular tension and or an experimental technique. There are no warranties or representations and, therefore, I accept responsibility for the consequences of my use of the information provided. I agree not to hold my practitioner liable of whatsoever kind or nature arising out of or in connection with my session(s).
If I experience any pain or discomfort during the session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort.
I understand the services provided should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a qualified medical specialist for any mental or physical ailment that I am aware of. Because massage/body work should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I forget to do so. It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless The Tree of Health Center’s practitioners from and against any and all claims or liability of whatsoever kind of nature arising out of or in connection with my session(s).
Furthermore, I agree that I have read this document and have provided true and correct information about myself. I give my permission for my credit card to be charged if I cancel an appointment with less than 24 hours’ notice or if I do not pay for a completed session with cash or a check.
55 Newton Sparta Road, Unit 107 - Newton, NJ 07860
973-500-8813 · www.ttohc.com · firstname.lastname@example.org