Dummy Intake Form

Personal Information

Contact Information

Primary Care Physician

Personal & Family Medical History

How do you generally feel about your work­out?

Goals & Other Information

Authorization and Disclaimers

I verify that all information is correct and current to the best of my knowledge. I further understand that DEMOR HotSpot Therapy should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a Physician, chiropractor or other qualified medical specialist for any mental or physical ailment. I agree to keep the therapist updated on any changes in my medical profile and understand that there shall be no liability on the therapist's part should I fail to do so. I understand that any information provided is for safety purposes and will be kept strictly confidential, except that such information may be used by DHST, Inc. for statistical analysis or scientific purposes.

I hereby give my consent to receive DEMOR HotSpot Therapy services and/or other bodywork and treatment (the Services) from DHST, Inc. and I acknowledge and agree that I am doing so at my own risk. My health and safety with respect to such Services are my sole responsibility. I acknowledge that my receipt of the Services from DHST, Inc. may result in bodily injury to me or my death. My decision to receive Services from DHST, Inc. is voluntary, and I know of, understand and assume any and all the risks associated therewith.

In exchange for receiving Services from DHST, Inc., I, for myself and on behalf of my heirs, executors, administrators and personal representatives, hereby waive, release, discharge and hold harmless DHST, Inc., its members, officers, employees and agents from any and all liability for any and all injuries, including death, damages or claims relating to or resulting from my receipt of the Services, now or in the future, foreseen or unforeseen. Further, I will indemnify and hold DHST, Inc., its members, officers, agents and employees, harmless from and against any and all claims, rights, damages, liabilities, losses, costs and expenses (including reasonable attorneys' fees) arising from or in connection with any injuries to other persons or damage to property caused by or attributed to me.

I, the undersigned participant, affirm that I am of the age of 17 years or older, and that I am freely signing this agreement. I certify that I have read this agreement, that I fully understand its content and that this release cannot be modified orally. I am aware that this is a release of liability and a contract and that I am signing it of my own free will.