Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Do you suffer from osteoporosis? *

Yes

No

Do you suffer from heart disease? *

Yes

No

Do you wear a pacemaker or other electrical implant? *

Yes

No

Are you pregnant? *

Yes

No

Do you have open wounds or skin diseases? *

Yes

No

Have you been seeing a doctor of illness and advised to rest or feel unwell including fevers? *

Yes

No

TERMS & CONDITIONS *

1) I understand payment is required on the day of consultation. 2) I understand appointments cancelled without a minimum of 24 hours’ notice will incur a fee of 50% of the full consultation price. If for whatever reason I am unable to make my appointment and do not notify Fitness4U, I will be responsible for 100% of the consultation price. 3) I acknowledge I have disclosed any relevant medical history/information/conditions/surgery and will continue to update Fitness4U of any changes/new conditions and/or medications 4) Information obtained by Fitness4U will remain confidential. Information may be used for internal research purposes to assist improved services. No personal details will be disclosed. 5) I understand and acknowledge should there be any damage to the equipment provided I will be required to pay for all replacement and repair costs incurred. 6) I understand that payments are non-refundable if the massage chair simply does not meet my expectations. By signing I acknowledge that I have read and agree to the above terms and conditions and acknowledge that I provide consent for treatment at my own risk.

I agree