Liz Jones Wellness, LLC
Jones Wellness Ranch
9829 County Road 1067
Greenville, TX 75401
715-684-9297
www.lizjones.co
YOGA and BODYWORK and PERSONAL TRAINING RELEASE AND CONSENT
I being aware of my own physical condition and the risks involved, am
voluntarily participating in physical activities at Liz Jones Wellness or during
training activities elsewhere. I hereby affirm that I do not suffer from any
condition or disability that would prohibit my participation in these activities.
I agree to assume full responsibility for any risks, injuries or damages which
I may incur as a result of participating in the program. Furthermore, I
release Elizabeth Jones, Liz Jones Wellness, LLC, Jones Wellness Ranch, its
instructors, agents, representatives, employees, contractors, successors and
assigns, from liability for any injury, damages, illness or death I may incur,
now or in the future, as a result of participating in these activities or as a
result of any negligent act or omission.
I agree to notify the practitioner of any injuries, disabilities or conditions
(including pregnancy) may limit (to any degree) your ability to participate in
physical activities.
I agree to inform each practitioner of any condition(s) so that she/he may
suggest appropriate precautions. However, I acknowledge yoga
instructors/bodyworkers/personal trainers are NOT medical professionals. I
agree to check with a physician or healthcare provider about the
appropriateness of specific activities for any condition.
I hereby give my consent to all photographs, audio and/or video recordings
taken of me by Liz Jones Wellness, LLC and Jones Wellness Ranch staff or
their designee. I understand that any such photographs, audio and/or video
recordings become the property of Liz Jones Wellness, LLC and Jones
Wellness Ranch and may be used by them, or others with their consent, for
educational, instructional, or promotional purposes in broadcast and
electronic media formats now existing or in the future created. I hereby
release Liz Jones Wellness, LLC and Jones Wellness Ranch and its teaching
staff, employees and agents from any and all claims for damages, libel,
slander, invasion of the right of privacy, or any other claim based on the use
of these images. I further acknowledge that I will not be compensated for
these images and that Liz Jones Wellness, LLC and Jones Wellness Ranch
exclusively owns all rights to the images and recording.
I have read and understood the above statement and voluntarily agree to its
terms and conditions.
In checking the box below I agree that is in no way responsible for the
safekeeping of my personal belongings while I attend class. I understand
that classes at may be physically strenuous and I voluntarily participate in
them with full knowledge that there is risk of personal injury, property loss
or death. I agree that neither I, my heirs, assigns or legal representatives
will sue or make any other claims of any kind whatsoever against or its
members for any personal injury, property damage/loss, or wrongful death,
whether caused by negligence or otherwise. [ ]
Confidential Client Intake Form and Release of Liability
Name: E-mail: .
Address: Home phone: .
City, State, Zip: Cell phone: .
DOB: Work phone: .
Occupation: Referred by: .
Emergency contact: Phone: .
Physicians name: Phone: .
General Health Information
Have you had professional bodywork before? If yes, how often do you
receive bodywork? .
Do you have any allergies or sensitivities to oils, lotions, scents, etc? .
What are your exercise habits? .
How much water do you drink daily? .
Are you under the supervision of a physician for any health concerns? .
.
Any current medications? .
.
Any surgical history? .
.
Please mark an (X) for current conditions and a (P) for past conditions
_ Abdominal/Digestive problems _ Chronic pain _ Hernia _ Rheumatoid
Arthritis
_ AIDS/HIV+ _ Circulatory/Heart problems _ High/Low Blood Pressure _ Sciatica
_ Headaches _ Currently pregnant _ Insomnia _ Severe Tension/Stress
_ Anxiety _ Depression _ Migraines _ Spinal disorders
_ Arthritis _ Diabetes _ Muscle Spasms/Cramps _ Sprains/Strains
_ Asthma or lung conditions _ Disc Problems _ Muscle injuries _
Varicose veins
_ Blood clots _ Fatigue _ Numbness/tingling _ Rash/fungus
_ Carpal Tunnel _ Fibromyalgia _ Osteoarthritis _ Tendonitis/Bursitis
_ Cancer _ Lupus _ Osteoporosis _ TMJ (jaw pain)
Other: .
Reason for today’s visit
What would you like to focus on with today’s treatment?
.
.
.
How long have you been having this issue? .
Have you sought medical attention for this issue? .
Have you tried and/or gotten relief with any other treatments? .
.
.
Liz Jones Wellness, LLC
Jones Wellness Ranch
9829 County Road 1067
Greenville, TX 75401
715-684-9297
www.lizjones.co
Please rate on a scale from 0 – 10 (10 being very high)
Stress Pain Energy
Please circle any areas of pain or tension on the diagram to the right
Please mark with an “X” any areas you would like avoided
(genital and breast areas will always be avoided)
Bodywork Client Waiver Form
Please take a moment to read and initial each of the following statements:
If I experience pain or discomfort during the session, I will immediately
inform my therapist so that
pressure/strokes can be adjusted to my level of comfort. I will not hold my
therapist responsible for any
pain or discomfort I experience during or after the session.
I understand that the services offered today are not a substitute for medical
care. I understand that my
therapist is not qualified to perform spinal or skeletal adjustments, diagnose,
prescribe, or treat physical
or mental illness.
I affirm that I have notified my therapist of all known medical conditions and
injuries. I agree to inform
the therapist of any changes in my health and medical condition. I
understand that there shall be no
liability on the therapist’s part should I forget to do so.
I understand that bodywork is entirely therapeutic and non-sexual in nature.
Liz Jones Wellness, LLC
Jones Wellness Ranch
9829 County Road 1067
Greenville, TX 75401
715-684-9297
www.lizjones.co
By signing this release, I hereby waive and release my practitioner from any
and all liability, past, present, and future relating to massage therapy and
bodywork.
I understand that should I cancel an appointment less than 24 hours before
the scheduled time or “no show” an appointment, I am subject to a fee
equal to the cost of the missed appointment. If the appointment was booked
under a gift certificate, it will be voided in lieu of the fee.
Information and Suggestions
o Prior to your bodywork, please remove contact lenses and all jewelry. Pull
long hair back with a clip or band.
o In general, Vedic Thai Bodywork is done while clothed in yoga or workout
gear. However (loose, comfortable clothing will not interfere with your
treatment).
During Vedic Thai Bodywork towels and sheets are used to cover you
occasionally, and you will be on the mat in just your clothing primarily your
session. This is your session and you should be as comfortable as possible, if
you would like to remain covered in a towel, please let the practitioner
know.
o Feel free to ask your practitioner any questions before, during, or after the
session. Your practitioner is a highly trained professional and wants to make
you feel informed and comfortable.
I have received the policy statement, and have read and agree to the
policies therein.
Client name:
Client signature:
Date:
Practitioner: Liz Jones
IF YOU DO NOT HAVE ACCESS TO A PRINTER, BY COMMENTING BELOW, YOU HAVE READ AND ACCEPT THE TERMS OF THE WAIVER. Write your full name and date to accept the terms of the waiver form.
or print form here