I understand that it is my responsibility to fully disclose my past and present medical history and any medication that I have previously or currently taken. I hereby acknowledge that the information I have provided, to my knowledge, is accurate at the time of consultation and it is my responsibility to notify my practitioner(s) at Body in Motion of any change of circumstance.

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Although I acknowledge that there are always risks with treatment, I wish to proceed with an initial consultation and any treatment that is recommended. I acknowledge that if I am claiming through an insurance company that I am responsible for paying any excess on the policy and any difference in charges.

I understand that I am responsible for paying for any appointments that I fail to attend directly to the clinic at the full rate.