Declaration *

I, affirm the accuracy, completeness, and authenticity of the information provided regarding my mental and physical health. This affirmation represents a meticulous and truthful account of my medical history, encompassing both present and historical conditions. Understanding the gravity associated with presenting inaccurate information, I acknowledge that such misrepresentation poses inherent risks not only to my personal well-being but also to the professional responsibilities of my therapist. I willingly and without coercion assume full responsibility for any untoward consequences resulting from my own negligence, including the undertaking of the prescribed treatment without anticipation of adverse effects. Acknowledging the broad responsibilities of Clinic 31, inclusive of its therapists, I hereby expressly and irrevocably release, discharge, and indemnify them from any and all liability for expenses, damages, claims, demands, actions, or causes of action arising out of or related to any illness, injury, or unforeseen circumstances resulting from or connected to the administration of Hijama, Sports Therapy & Spinal Manipulation. This comprehensive release and indemnification extend to any agents, employees, successors, assigns, or third parties associated with Clinic 31, unless death or personal injury arises from proven negligence on the part of Clinic 31 or its therapists. I have been provided with exhaustive information outlining the contraindications associated with the specified therapeutic interventions. In full awareness of the inherent risks, I willingly and autonomously consent to proceed with the prescribed treatments, understanding that these interventions may involve physical touch, manual adjustments, or other therapeutic techniques. I further acknowledge and understand the confidentiality of this information, explicitly granting permission for disclosure solely upon my express consent. I acknowledge that my health information may be used for administrative, billing, and clinical purposes. In the event of any substantive alterations to my health status, it is my commitment to communicate promptly with the therapist to ensure that the therapeutic approach remains aligned with my evolving health needs. By my signature below, I hereby release, waive, discharge, and covenant not to sue the therapist, Clinic 31, its agents, employees, successors, assigns, and any third parties from any and all liabilities arising from the prescribed treatment, including but not limited to negligence.