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Please fill out this form before coming to your session. Thank you for booking with us.

Birthday

I understand that if I experience any pain or discomfort during a session, I will immediately inform the practitioner so that the pressure and/or application may be adjusted to my level of comfort.


I understand that massage therapy and holistic uterine education should not be construed as a substitute for a medical examination, diagnosis or prescription. I should see a Gynecologist, Reproductive Endocrinologist or other qualified medical specialist for any physical ailment or suspect condition I might have.


I understand that this therapeutic work is not intended to take the place of medical/surgical intervention and my practitioner, Courtney Kirkby, Registered Massage Therapist, shall not bear any responsibility for any ill effects should I choose to not adhere to my primary doctor’s advice.


I understand that the practitioner is not qualified to diagnose, prescribe or treat any emotional or mental distress and nothing said in the course of the session(s) given should be construed as such.


I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there will be no liability on the practitioner, Courtney Kirkby RMT should I forget. 


I will honuor all office policies including but not limited to payment, cancellation notice, tardiness, and conduct.


I have read, fully understand, and agree to the above terms and conditions.

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