I, the undersigned, certify that I (or my dependent) will be responsible for payment for services rendered. I understand that the information which I have provided on this form is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform the staff of Body Mind ReNew of any changes in my medical status. I will immediately notify the Body Mind Renew of any pain or discomfort during the treatment. I
affirm that I have stated all known medical conditions, and answered all questions honestly. I agree to inform Body Mind ReNew of any changes in my health status, and I understand that there shall be no liability against Body Mind ReNew for my failure to do so.I waive and release any and all claims for damages that I may have against Body Mind ReNew, its owners, staff, associates, attendants, and affiliates. I agree to hold Body Mind ReNew harmless and indemnify it for any incident(s) which may arise,
past, present, or future, from my use of services provided by Body Mind ReNew."
I have read and understand the following statements: Always consult your physician before considering alternative treatment therapy. Some ailments and conditions may be contraindications for receiving alternative treatment therapy. Treatments provided by Body Mind ReNew should not be construed as a substitute for medical examination, diagnosis, or medical cures, and you should seek a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which you are
I have read and understood the form in its entirety. By entering my first and last name, and clicking the submit button on this Form I am indicating that I have read, agree to, and understand this form.