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Consent for Session and Waiver of Liability

Intake and Consent/Liability Forms PDF

The undersigned ("client") hereby freely consents to receive services from DEBORAH GOALDMAN, REGISTERED PRACTITIONER OF ORTHO-BIONOMY® AND REIKI MASTER.
Client agrees to the following: I have stated all of the conditions that I am aware of, and this information is true and accurate. I will inform the practitioner of any changes in my status. I understand that there shall be no liability on the practitioner's part should I fail to do so. I understand that if I become uncomfortable for any reason, I may ask the practitioner to end the Ortho-Bionomy® and/or Reiki session, and she will end the session. I understand that the practitioner may end the session for behavior that is inappropriate or sexually suggestive, and payment will be expected in full regardless if the session is completed or not.

  1. I understand that Ortho-Bionomy® and Reiki are designed to be an ancillary health aid and are not suitable for primary medical treatment for any condition.
  2. The potential benefits and possible side effects of Ortho-Bionomy® and Reiki have been explained to me. I have been given an opportunity to ask questions of the practitioner and have received all requested information.
  3. I agree to immediately inform the practitioner of any unusual sensation or discomfort so that the application of position and movement may be adjusted to my level of comfort.
  4. I understand that Ortho-Bionomy® and Reiki practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.
  5. I hereby assume full responsibility for receipt of the Ortho-Bionomy® or Reiki, and release and discharge the practitioner Deborah Goaldman from any liabilities or claims made by myself or any of my relatives now or in the future.
  6. I, ___________________________________________ in signing this Consent for Ortho-Bionomy® and Reiki and Waiver of Liability, understand and agree that this Consent and Waiver will apply to and govern the current and all future sessions performed by the practitioner.

Client's Signature_________________________________________

Client's Printed Name _____________________________________ Date __________

Practitioner's Signature_________________________________________

Practitioner's Printed Name Deborah Goaldman Date __________