Patient Liability Form

Please initial

Patient Liability Form

I have answered truthfully on all forms received of my known physical

and mental conditions, along with any medications. I will keep the staff         

updated on any changes. I understand that I cannot hold my provider 

liable for any pertinent information I have not relayed.                                        _______

If I experience any pain or discomfort during the session, I will 

immediately communicate that to the provider so the treatment can 

be adjusted. I am aware that I may terminate the treatment at any 

point during the session, at my discretion and without reason.     _______

I am aware that I may experience some possible side effects from 

treatments such as temporary discomfort within the muscle

for two to three days post treatment, and that I may also experience 

bruising, headaches, or dizziness.     _______

I will not disrespect, demand nor test personal and professional 

boundaries with my provider or any of the staff. I understand that

I will not hold Sunrise Healing Center or the provider responsible for 

any injury, nor are they responsible for any lost, stolen, or damaged 

articles.     _______

I am aware that it is not necessary to remove articles of clothing 

for treatment and that I can decide to remove my belongings that 

which makes me comfortable. I will refrain from undressing until 

the massage therapist leaves the room.     _______

I understand that I must maintain personal clean hygiene prior to my 

arrival. That includes bathing, maintaining clean clothes, oral and other

personal hygiene.  I understand that this aids in the prevention of 

spreading disease and is vital to maintain patient/provider health.                   _______

I understand that the time slot reserved for my massage includes times 

for interviewing, assessment, the actual massage treatments, any involving

additional therapy, case follow-up, remedial exercises, as well as dressing

and changing clothing as required.   _______

I understand if Sunrise Healing Center is not able to run my benefits, it is 

ultimately my responsibility to be aware of my records and keep track of 

each visit I am allowed. I am aware that if my insurance does not cover my 

visits, I am ultimately responsible to pay and can be put on a payment plan 

if requested.   _______

Promptness is expected for all appointments. In the event of lateness, the 

treatment may be cut short due to other commitments of providers. Fees

will be maintained per the schedule. Cancellation of any appointments 

must be received at least 24 hours in advance, otherwise 50% of any

treatment fee is due and 100% if it becomes habitual. Fees for treatment 

are due prior to departure on the day of the treatment. Cash, credit cards, or personal checks are accepted.

_______

We have the right to refuse service to anyone who does not abide by any of 

these rules and regulations.

Patient Printed Name: _____________________

Patient Signature: _________________________

Date: _____________________

(Original Copy, June 2023)