ALAMBA
***If you have already completed and signed this Intake Form and Waiver, and there are no changes to your personal or medical information, you do not need to fill it out again***
Name
Birthdate
Email Address
Phone Number
Emergency Contact Name
Emergency Contact Phone Number
Please answer the following to help us understand your needs and ensure your safety:
Do you have any medical conditions, injuries, or chronic illnesses?
yesno
If yes, please describe:
Are you currently pregnant?
If yes, how many weeks pregnant are you?
Are you taking any medications that may affect your participation?
If yes, please list:
Have you practiced yoga, sound healing, or Access Bars before?
If yes, what have you practiced:
What are your primary goals or reasons for attending these sessions?
Do you have specific areas of concern or focus?
Some individuals may experience discomfort with certain sound frequencies or vibrations.
Do you have any sensitivities to sound or vibration?
Do you have difficulty lying on your back?
Have you had any accidents or surgeries in the last 2 years?
Do you have any implants, pacemakers, etc.?
yes, please add me to the mailing list.no, thank you.
At Alamba, we prioritize your safety and well-being. However, yoga involves physical activity that carries inherent risks. By signing this waiver, you acknowledge and accept these risks, releasing Alamba and its teachers from liability.
I understand and agree that Yoga involves physical movements, stretching, and strength-building exercises that may cause injury. It is my responsibility to inform the instructor of any injuries, medical conditions, or limitations before participating in the class. I will listen to my body and practice within my own physical limits. Alamba and its teachers cannot guarantee injury-free sessions. I will immediately inform the teacher if I experience pain, discomfort, or dizziness during the session.
If I experience pain or discomfort during the session, I will immediately inform my therapist so that any pressure or techniques applied can be adjusted to my level of comfort. I will not hold my therapist for any pain or discomfort I experience during or after the session.
I understand that the services offered today are not substitute for medical care. I also affirm that I have notified my therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist part should I forget to do so.
Sound bath/healing/therapy, Access Bars is contraindicated for certain medical conditions. I affirm that I have discussed all my known medical conditions whit the therapist, and completed the information on this consent honestly. I understand that I should see a physician or qualified medical specialist for any mental or physical ailment of which I am aware. I agree to keep the therapist updated as to any changes in my medical/physical conditions that might affect my ability to safely receive my Sound bath/healing/therapy and Access Bars.
By signing this release, I hereby waive and release Sound bath/healing/therapy and Access Bars of Alamba and my therapist from any and all liability, past, present and future relating to Sound bath/healing/therapy and Access Bars of Alamba.
I understand that should I cancel or reschedule an appointment less than 24 hours before the scheduled time or don’t show up to the appointment, I am subject to a fee equal to the full cost of the missed appointment. I also understand all sales are final, no refunds.
In general, Sound Bath/healing/therapy, and Access Bars is done while fully clothed. This is your session and you should be as comfortable as possible, wear comfortable clothes.
Sound Bath/healing/therapy, and Access Bars is professional service. Inappropriate or sexual conduct of any kind, initiated by any party will not be tolerated. If uncomfortable for any reason, the client or therapist may ask to end the session, and the session will end.
We collect personal information to provide you with the best yoga, sound healing, and Access Bars services. This may include: Contact Information, Medical Information, Sound Sensitivity, etc. We do not sell or rent your personal information.
For participants under 18 years of age this waiver must be signed by a parent or legal guardian. The parent or guardian assumes all risks and responsibilities on behalf of the minor.
I have received this privacy policy agreement and have read and agreed to all of the policies therein.
Signature (use mouse or finger)
Date
Are you under 18 years of age?-- Yes or No --YesNo
Parent/Guardian Name
Parent/Guardian Signature (use mouse or finger)