I, the undersigned, certify that I (or my dependent) should honestly answer all health related questions. I understand that I am financially responsible for all charges. I understand that the information I have given today 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 Body Mind Renew of any changes in my medical status. I understand that the treatments offered by Body Mind Renew are not a substitute for visits to my regular HealthCare Provider. I should advise the Body Mind Renew attendant of any pain, discomfort or concerns which I may experience during treatment. I should consult with my HealthCare Provider for any Health Concerns. By completing the Client Signatrure line below and clicking the Submit Button, I hereby give my consent to be treated by Body Mind Renew.