New Client Info New Client Info Name * First Name Last Name Email * Phone * (###) ### #### Emergency Contact * Please list contact's name, relationship to you, and phone number. Communication Preference Please indicate if you prefer text of email communication. Text communication is considered the default if no selection is made. Text Email How did you hear about us? Thank you! Assumption of Risk Assumption of Risk Name * First Name Last Name Assumption of Risk * Please check all boxes to indicate agreement. I am participating in activities including but not limited to stretching, strengthening, wellness, body work (hereafter referred to as “Wellness Programs”) and/or externally applied modalities (hereafter referred to as “Modalities”) including but not limited to compression therapy, light therapy, cupping during which I will receive information and instruction about fitness and health. As is the case with any physical activity, including my voluntary participation in Wellness Programs and Modalities, I recognize that Wellness Programs and Modalities require physical exertion, which may be strenuous and may cause physical injury and I am fully aware of the risks and hazards involved. I affirm that I alone am responsible in deciding whether to participate in Wellness Programs and Modalities. I acknowledge that I have decided to participate in Wellness Programs voluntarily and do hereby assume all responsibility for my participation in any activity associated with StretchAbility, LLC including but not limited to Wellness Programs and/or Modalities. I certify that I am physically well and have no medical conditions, impairments, diseases or any other illness that would prevent my full participation or increase my risk of injury and/or illness as a result of partaking in any Wellness Program and/or Modalities. While engaging in any Wellness Programs, Modalities, or activity operated, organized, arranged or sponsored by StretchAbility, LLC I shall do so at my own risk. I acknowledge and represent that I have been advised to consult with my physician prior to and regarding my participation in any activity with StretchAbility, LLC with respect to any past or present injury, illness, cardiovascular problems, orthopedic problems, neurological problems, osteoporosis, or any other condition that may affect my participation and ability to participate in and to endure the Wellness Programs and/or Modalities, and knowingly assume all risks relating to my participation in the StretchAbility, LLC activities. I acknowledge that I have discussed with my physician the appropriateness of the Wellness Programs and Modalities activities offered through StretchAbility, LLC in connection with any illness or condition that I now have or have previously had and that I knowingly execute this agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. I have read this agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. This agreement is intended to be as broad and inclusive as permitted by law. If any portion of this agreement is held invalid, the remaining portions will continue in full force and effect. Type name to indicate signature * Thank you! Health Info Health Info Name * First Name Last Name Date of Birth * MM DD YYYY Checkbox * Check all that apply Orthopedic History Cardiac Disease Pulmonary Disease Neurological History Cancer Diabetes Recent Injury Please describe any current conditions: Thank you! Informed Consent Informed Consent Name * First Name Last Name I hereby acknowledge and agree that: * I have read, understand, and am bound by these Wellness Services Policies & Procedures, and I have truthfully and to the best of my knowledge provided the information requested Wellness Services and their risks and benefits (if any) have been explained to me Wellness Services may not give me the result that I expect, and I have been informed as to other possible services that may provide me a benefit Wellness Services are not an exact science, and Wellness Services are provided to me without any warranty or guarantees about any result I have had ample opportunity and time to discuss my concerns with StretchAbility, and all of my questions have been answered to my satisfaction I shall indemnify StretchAbility and its principals and employees I voluntarily assume all risks of receiving Wellness Services Type name to indicate signature * Thank you!