Functional Movement Techniques Waiver

Name *

First Name

Last Name

I affirm that I have informed my practitioner of all known medical conditions, surgeries, allergies and injuries. *

Yes

I understand that FMT services are not a substitute for medical care in any form. *

Yes

I understand that all sessions are therapeutic in nature. If I experience pain or discomfort during the session, I will immediately inform my practitioner of such. I will not hold my practitioner responsible for any pain or discomfort or skin discolouration or any other side affects that may result during or after the session. *

Yes

I understand that any skin discolouration that may occur as a result of treatment is not bruising. I further understand that this reaction will dissipate in any time frame from a few hours to as long as a few weeks in some cases. *

Yes

I agree to inform the therapist of any changes in my health and medical condition. I understand that there will be no liability on the practitioner’s part should I neglect to do so for any reason. *

Yes

I understand that after treatment I may experience side effects. These side effects may include: nausea, headache, dizziness, tiredness, flu like symptoms, etc. These will be reduced with rest and plenty of water. *

Yes

I understand that I should avoid: extreme temperature conditions (either hot or cold) (hot showers, saunas, hot tubs, weather conditions), excessive exercise, caffeine, alcohol, and high sugar food or drinks for a minimum of 4 to 6 hours post session. I understand that exposure to any of the above could produce undesirable effects. *

Yes

By signing this release, I hereby waive and release my practitioner, LeeAnn Freymond and Three Three Eight from any liability, past, present, and future relating to functional movement techniques in any form. *

Yes

I have reviewed the policy statement and have read and agree to the policies therein. *

Yes