Services by THAI MOTION THERAPY

To assist me in getting to know you a little better as a first-time thai yoga massage client, please fill out the following:

First Name *

Last Name *

Cell Phone

Email *

Date of Birth *

Address *

Street Address

City

State

Country

Postal Code

Emergency Contact Name *

Emergency Contact Number *

Current activity/fitness routine or physical limitations

What are your goals for this session?

Acknowledgement *

I confirm that the information provided in this form is true and complete to the best of my knowledge. I have read and understood the contents of this form and acknowledge that it is my responsibility to inform my therapist of any changes to my health status.

Liability Waiver and Assumption of Risk Form

1. I understand and acknowledge that THAI MOTION THERAPY (the “Company”) is offering a variety of services and that the services provided by the Company at Balance Wellness, ATELIER or Oxygen Yoga and Fitness primarily include but are not limited to, thai yoga massage. I understand and acknowledge that there are certain risks, dangers, and perils inherent in the use of Company services including the possibility of injury ranging in severity from minor to fatal which I hereby assume and certify that I do so of my own

free will, being under no compulsion or duress.

2. In recognition of the inherent dangers involved in the services provided by the Company, I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation in or use of services, equipment or machinery except as stated in the Client Health Profile which I have completed.

3. In consideration of the opportunity to participate in services provided by the Company and to use its services in addition to the payment of any fee or charge, I, for myself, my heirs, executors, administrators, successors and assigns hereby and forever discharge and release the Company, its employees, agents, officers, directors, and representatives (collectively, the "Releases"), as well as release Balance Wellness, ATELIER and Oxygen Yoga and Fitness from all debts, claims, demands, damages, actions and causes of action whatsoever including, without limiting the generality of the foregoing, claims arising out of the negligent act or omission of any of the Releases or others acting on their behalf or in any way arising out of or connected with my participation in any services provided by the Company.

4. This Liability Waiver and Assumption of Risk Form shall apply to all services received by me from the Company from time to time from and after the date hereof

Signature *

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