Waiver & Release
of Liability

If you have trouble filling out the online form, please print and use the form below:

WAIVER & RELEASE FORM

Please fill out the following form
before receiving your first treatment.

First Name

Last Name

Email

Date of Birth

Have you been hospitalized in the last 12 months? *

No

Yes

Are you suffering from a medical condition, illness, or injury? *

No

Yes

If you answered yes to any question, please elaborate

GENRAL HEALTH QUESTIONS: CHECK THE BOX FOR 'YES'

Have you ever experienced energy work before?

Do you have any goals or area(s) you would like to work on?

Please list any major surgeries, injuries, or illnesses you have experienced.

Do you drink alcohol? If so, how much per week?

Do you smoke? If so, how often?

How much sleep would you say you get on average?

LIABILITY RELEASE

Your Signature

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

2 Journey

Suite #108

Aliso Viejo, California 92656

call: 949.607.9228 email: info@solholisticspa.com

@2021- 2024 Black Widows LLC

Email

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