Please take a moment to carefully read the following information and sign by typing your initials below. If you have a specific medical condition or specific symptoms, any of these modalities may be contraindicated. A referral from your primary care provider may be required prior to service being provided.
I understand that if I experience any pain or discomfort during any session, I will immediately inform
the practitioner. Additionally, if I am receiving a vaginal steam bath, I will let the practitioner know if the heat is too hot so that the temperature may be adjusted to my level of comfort.
I further understand that these modalities should not be construed as a substitute for medical
examination, therapy, diagnosis, or treatment and that I should see a physician, therapist or other qualified medical or counseling specialist for any physical or mental ailment of which I am aware.
I understand that the practitioner facilitating the healing is not qualified to diagnose, prescribe, and/or treat any physical or mental illness, and that nothing said in the course of any session given should be construed as such. Because each of the above named modalities should not be performed under certain medical conditions, I affirm that I have stated all of my known medical conditions, and answered all questions accurately, completely, and honestly.
I agree to keep the practitioner updated as to any changes in my medical profile and understand that
there shall be no liability on the practitioner's part should I forget to do so.
I am aware and I understand there is a possibility that my IUD can come out due to a Maya Abdominal Therapy session or a Vaginal Steam Bath. This has been explained to me and I am going ahead with the Vaginal Steam Bath at my own risk.
I understand that I am proceeding to receive any of these healing modalities at my own risk and hereby release Jeevan Singh from any liability.