DEMOR Intake Form


Thank you for Your Submission!!!

























Do you pharmaceutical for discomfort or pain?
Do you have any old or current injuries which currently cause you discomfort or pain?
Do your discomfort or pain causes you to feel in your movement, check all that apply:





Do your discomfort or pain causes you to feel in your mind, check all that apply:





Do you have difficult laying on your front, back, or side?
Do you have allergies to oils, lotions, or ointments?
Do you wear contact lenses?
Do you wear dentures?
Do you wear hearing aids?
Do you currently participate in cardiovascular training?
Do you currently participate in resistance (weight) training?
Do you currently participate in a stretch training?
Do your sit at your workstation without regular breaks?
How do consistently feel stress in specific areas of your life?








Male and female genitalia and women's breasts will not be exposed or massaged at any time. Draping will be used during the session and only the area being worked on will be uncovered.

Initials:

This is a therapeutic bodywork session and any sexual remarks or advances will terminate the session immediately and you will be liable for payment of the scheduled treatment.

Initials:


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.


DEMOR HotSpot Therapy®

Office: (949) 861-4378
Toll Free: 1 (866) 336-6755
5001 Birch St, Newport Beach, CA 92660
Today 9:00 am – 6:00 pm
info@demorhotspottherapy.com

PLEASE CALL US AT
(949) 861-4378
to SCHEDULE A SESSION

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