Name
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First Name
Last Name
Preferred Name (if different)
Email
*
Home Phone
*
(###)
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Mobile Phone
(###)
###
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
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MM
DD
YYYY
Gender
*
Emergency Contact Name
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First Name
Last Name
Emergency Contact Relationship
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Family Doctor
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Family Doctor Phone
*
(###)
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How did you hear about us?
Current Health Conditions (Reason for visit)
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When did it start?
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How did this condition begin?
Are you currently experiencing any pain?
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For women only: Are you Pregnant?
For Women Only: Are you nursing?
Describe your health goals
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Are you currently under the care of a Chiropractor, Functional or Naturopathic Doctor?
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If so, for what reason and did it help?
Health History:
Indicate if you have a history of any of the following:
Traumas: Physical History.
Have you every had any significant falls, surgeries, accidents or injuries as an adult?
How many hours per day do you typically spend sitting?
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How do you wake up in the morning?
Diet Choices: What do you follow, if any?
Do you have any allergies? To medication, food or substances?
*
Consent Form
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I hereby acknowledge under oath that I am the client of Rest and Restore, LLC and I hereby give my permission to participate in Lymphatic Therapy and EVOX therapy and any other services offered by Rest and Restore Wellness, LLC.
As an integral part of such permission, I recognize that Lymphatic Therapy is a naturalist, experimental, alternative procedure whose purpose is not in diagnosing, healing, or curing; but to help promote good health and well-being.
Therefore, I hereby agree to hold Rest and Restore, LLC harmless from and against any and all claims, demands, liabilities, actions, causes of actions, damages, and/or expenses, of any nature and kind without limitation, arising from my direct or indirect participation in any of the aforementioned therapies.
I hereby acknowledge that I assume the risk of any and I will assume all damages if ever needed. I waive any cause of action that I might have at any time against Rest and Restore, LLC or that I might thereafter accrue as a result of any therapeutic services.
I have had an opportunity to review this waiver and ask any questions concerning its meaning or intent. I verify that I have read this entire document, have had reasonable opportunity to ask questions concerning its application, understand its contents, and acknowledge that the various information provided throughout this document is accurate and complete.
I further acknowledge and verify that I have full legal authority to execute this document and there are no requirements, conditions, or obligations, legal or otherwise, which would require the consent or assent of any other person or entity.
Electronic Signature Agreement
*
By checking the box and clicking "Submit," you acknowledge that you have read, understood, and agree to the terms outlined in this consent form. You agree that your electronic signature is the legal equivalent of your handwritten signature and that you are voluntarily providing your consent.
First Name
Last Name
