Please include any accidents, surgeries, etc and dates they occurred
Such as yoga, tai chi, meditation, etc
Please describe the addiction (smoking, drinking, food, drugs (prescribed or recreational/illegal), sex, gambling, other) and frequency
Please describe the issue and frequency
Please describe the issue and include frequency
I understand that massage therapy, breath work, plant healings, yoni steams, coaching, recommendations, and protocols I am offered by Natalie Gentry/Holistic Health Space, LLC, are for the purpose of stress reduction, relief from muscular tension or spasm, and are for increasing energy, circulation and general physical and emotional well being. I understand that Natalie Gentry/Holistic Healing Space, LLC does not diagnose illness, disease, or any other physical, mental or emotional disorder. I understand that Natalie Gentry/Holistic Healing Space, LLC does not prescribe medical treatment, medications or perform spinal manipulations. I understand that Natalie Gentry/Holistic Healing Space, LLC provides services related to massage therapy, breath work, movement, plant healing, yoni steams, nutrition consultation, and body-centered coaching only. I understand that services provided at Natalie Gentry, LLC/Holistic Healing Space, LLC are not a substitute for medical examinations or treatment, and that it is highly recommended that I consult with a physician/health care provider about any medical condition. I have stated and described to the best of my ability all my known medical conditions to make Natalie Gentry/Holistic Healing Space, LLC aware of my existing physical, mental and emotional conditions. I agree to keep this information updated. I give Natalie Gentry/Holistic Healing Space, LLC permission to provide treatment to me. I reserve the right to question the purpose and risks of recommended care, and to request reasonable alternative forms of treatment. I understand that there is a 48-hour cancellation policy (inclement weather and illness excepted). If I cancel my appointment with less than 48-hours notice, I accept that I will be charged the full amount of my reserved session. I understand that payment for individual sessions, MAM Basic Target Treatment program, and the 4-session massage packages are due at time the first services are rendered. I understand that the MAM Complete Target Treatment program and the Return To Self private and group programs can be paid in installments and that I am agreeing to be responsible for paying for the complete cost of the programs I sign up for. I understand that packages need to be completed in the following time frame and that the completion dates start from the date of the first treatment received: Maya Abdominal Massage Basic Target Treatment program: Three sessions completed within 4 months Four-session massage packages: Completed within 6 months Maya Abdominal Massage Complete Target Treatment program: Six sessions completed within 8 months Return To Self Program: Time frame TBD I understand that, unless alternative plans are made in advance in writing, any portion of my program fee or package fee that is unused in accord with the above applicable timeframe will be forfeited to Natalie Gentry, LLC. I understand that Natalie Gentry/Holistic Healing Space does not provide refunds for unused services purchased. I acknowledge that Natalie Gentry/Holistic Healing Space, LLC, have not and will not make any guarantees regarding the likelihood of success or outcomes of any information, treatment, services or products provided to me. I hold Natalie Gentry, LLC/Holistic Healing Space LLC, and all agents and contractors harmless regarding any/all legal disputes regarding services rendered. If litigation is warranted, I can only claim reimbursement of money regarding the session being disputed. This Agreement is governed by the laws of the State of Colorado. Any disputes will be settled via mediation. I am legally able to enter into binding contracts.
