Please read, and sign, this disclaimer and send to me BEFORE I begin my work with you. Just fill out and snap a picture and send to my email at [email protected]
.
I freely acknowledge that I am fully aware that Marcella Regal is not a medical doctor or any other kind of medical practitioner and she has not represented herself in any way as possessing any medical expertise or medical training whatsoever and she has not prescribed, diagnosed, treated or recommend any particular treatment, medication, or substance for me in respect of my injury, ailment, or disease that I may possess.

I have not been cajoled, coerced, threatened, or persuaded by Marcella Regal to undergo or partake in any particular treatment, medication, or substance – and that I freely acknowledge that any unorthodox or unusual treatment or medication or substance that I may utilize is done with my full awareness and acknowledgement that it is of my own free will.

I, the undersigned, for myself, my heirs, hereby release and forever discharge Marcella Regal, from any and all actions, causes of action, claims and demands for or by reason of any damage, loss or injury, to person and property which heretofore has been or hereafter may be sustained in consequence of attending a workshop, or taking of any medication, substance, or treatment which I may use or consume in any respect of and for any attempts by myself or anyone on my behalf to cause temporary or permanent relief from the symptoms of any injury, ailment, or disease with which I have been or will be diagnosed.

I have read and understood that Marcella Regal’s fees are to be prepaid before my appointment is scheduled and that the fees are non-refundable. If I need to reschedule my appointment, I will not be entitled to a refund unless I have provided 24 hours notice. If I miss my appointment I will not be entitled to a refund.

Fixx your health performs acupressure massage services for therapeutic purposes only. It is understood that any inappropriate behavior such as excessive drinking, drug use, illicit or sexually suggestive remarks, or advances made by the client will result in immediate termination of the session, and the client will be liable for payment for the “full” scheduled appointment. After the dispute is evaluated by Fixx Your Health, and we determine that the client was at fault, we have the right to process the client’s credit card.

___________________________________
Print Name

___________________________________
Street Address

___________________________________
City, State, ZIP or Region

___________________________________
Country

___________________________________
Telephone

___________________________________
Alternate Phone

___________________________________
Occupation

___________________________________
Referring Physician & Phone (if applicable)

___________________________________
Date of Birth

___________________________________
Alternate Contact & Phone

_________________________________________________
What are your requested appointment times & dates?

_________________________________________________
When is a good time to call to schedule your appointment?

____________________________________________________________________________
What issues do you want healed or addressed?

____________________________________________________________________________
What alternative treatments have you received or are currently working on?

____________________________________________________________________________
Please list all medications and herbs that you are taking

____________________________________________________________________________
Additional comments about things you would like me to know that you feel would be helpful information for me to know in assessing your issues and facilitating your healing.

If you are receiving a Shiatsu, please do not make an appointment if you have the following conditions: fever, cancer, leukemia, skin infections, contagious diseases, pregnancy (first trimester), recent surgery, injury or trauma within 24 hours, intoxication due to alcohol or drugs. Do you have any of these conditions (please circle): YES/NO

If you are receiving energy healing, I need to know if you have diabetes or heart disease beforehand. Do you have any of these conditions (please circle): YES/NO

ADDITIONAL INFORMATION FOR PETS:

___________________________________
Pet’s Name

___________________________________
Pet’s Age

___________________________________
Pet’s Species

PLEASE EMAIL A PHOTO

___________________________________
Signature

___________________________________
Print Name

___________________________________
Date

I keep all of our interactions completely confidential. I will listen carefully and pay specific attention to your desires for healing and will then dedicate my focus toward helping you resolve your issues. I love helping people meet their personal goals and expectations.