Alternative Therapy Waiver Form
Complete this form to request an alternative therapy session and acknowledge the waiver before participation.
Participant Information
Participant Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternative Therapy Session Details
Therapy Type / Service Requested
*
Please Select
Acupuncture
Aromatherapy
Cupping Therapy
Energy Healing
Herbal Consultation
Massage Therapy
Meditation Session
Reflexology
Reiki
Sound Therapy
Other
Preferred Appointment Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Practitioner or Location Preference
Waiver Acknowledgment and Signature
Participant Signature
*
Submit
Submit
Should be Empty: