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Detox & Bodywork Information Form

SoHA & Awareness Studios
6255 Barfield Rd. Suite 110 • Atlanta GA 30328
(404) 257-1257 • www.SoHAonline.org

Name *
Name
Phone *
Phone
country code (not required within the U.S.)
Address *
Address
Birthday *
Birthday
Would you like to be on our mailing list?
Have you had massage therapy previously? Castor Oil treatments? Magnesium Wraps? Is there anything you would like us to know before these or any other scheduled body therapies?
What illnesses or surgeries have you had? When did they occur and what was the treatment? [This information is confidential.]
Are you currently under the care of a physician and/or chiropractor? If so, for what?
Are you currently on any medications? Which ones? [This information is confidential.]
Include topical, inhaled, or ingested irritants and allergens.
Cancellation Policy *
SESSIONS *24-hour notice of cancellation for scheduled appointment is required (except in emergency) to avoid full charge for the session. COURSES * If you cancel your attendance more than 1 week before the course date, your tuition will be refunded, less the deposit. The deposit may be rolled to your next course registration. * If you cancel your attendance less than 1 week prior to the course date, your entire tuition will be forfeited. An exception to this policy will be made if you are hospitalized or if you are attending the funeral of a member of your immediate family.
Agreements and Consent for all Massage and all Body Treatments *
If I have an emotional or physical diagnosis or am under the care of a physician, or have been hospitalized or are currently under the care of a psychologist or psychiatrist, I understand that it is required that I attend the detox treatment, colonic, massage, body treatment session only with written permission of my doctor or therapist. I take responsibility for consulting with a medical doctor prior to participating in any detox treatment, hydrocolon (colonic) therapy treatment, massage and/or bodywork at School of Humanity & Awareness, Inc, Awareness Studios, LLC, Vibrancy, LLC, Holding Consciousness, LLC, Replenish IV by Nomad MD, LLC. I assume the risk, by this consent, of any illness or injury during, or after any colonic, detox treatment, massage, body therapy session, and hereby release School of Humanity & Awareness, Inc, Awareness Studios, LLC, Vibrancy, LLC, Holding Consciousness, LLC, Replenish IV by Nomad MD, LLC, and/or Apollonia Fortuna, and/or any associated practitioner from liability therefore. Informed Consent for all Programs, Courses, Sessions 1. I understand this program/course/session is educational and therapeutic for detoxing the body and not psychotherapy/medical treatment or a substitute for psychotherapy/medical treatment. I understand that this program/course/session can be a life-changing experience. I understand that I may undergo a deep transformation of my life due to realizations and understandings in this program/course/session. I am prepared to seek support afterwards with regards to this transformation. I understand that SoHA, Awareness Studios, LLC, Vibrancy, LLC, Apollonia Fortuna and all staff, do not claim to "cure" any issue. 2. I have discussed the program/course/session with a staff member. I assume the risk, by this consent, of any accident of injury to myself or inflicted by me. I take responsibility for consulting with a medical doctor prior to participating in the program/course/session concerning any known or potential physical or mental condition, for the purpose of getting medical permission to participate. and hereby release Holding Consciousness, LLC, Awareness Studios, LLC, Sukhavatia, LLC, Vibrancy, LLC and/or School of Humanity & Awareness, Inc., Apollonia Fortuna and/or any associated staff, interns or instructors from liability therefore. 3. I hereby authorize the staff members of SoHA, Inc and Awareness Studios, LLC, to take any reasonable step on my behalf in the case of accident, injury or illness, including but not limited to emergency first aid; doctor; nurse; or ambulance services, etc. I agree to be liable for the cost of any such action taken on my behalf, and hereby release Holding Consciousness, LLC, Awareness Studios, LLC, Sukhavatia, LLC, Vibrancy, LLC and/or School of Humanity & Awareness, Inc., Apollonia Fortuna and/or any associated staff, interns or instructors from liability therefore. Liability Release for all Activities As a consideration for being permitted by School of Humanity & Awareness, Inc, Awareness Studios, LLC, Vibrancy, LLC, Holding Consciousness, LLC, Sukhavita, LLC, B Training, LLC and/or Apollonia Fortuna to participate in these activities and use their facilities, I hereby agree that I, my assignees, heirs, distributes, guardians, and legal representatives will not make claim against, sue, or attach the property of its affiliates, owners, employees, agents, volunteers, or sub contractors or any of its affiliated organizations for injury or damage resulting from acts, howsoever caused, as a result of my participation in this event or series of sessions. I hereby release the School of Humanity & Awareness, Inc, Holding Consciousness, LLC, Awareness Studios, LLC and Vibrancy, LLC, Sukhavita, LLC, B Training, LLC and/or Apollonia Fortuna (and all staff, interns and teachers) from all actions, claims or demands, that I, my heirs, my assigns, distributes, guardians and any legal representatives now have or hereafter have from all actions for injury or damage resulting from my participation in this event or session.
Signature *
Signature
By typing my name in the box below, I am acknowledging that I am at least 18 years of age and have read and agree to the Informed Consent and Cancellation Policy above.
Today's Date *
Today's Date