Stop Smoking Hypnosis Registration and Waiver

Please highlight this form and hit <control> P to print it out.  Please fill it out and bring it with you to your first session.  You may also copy and paste it into an email and submit it electronically.

Name_______________________________________Birth Date_____________________

Best Phone to reach you_____________________________________________________

Back-up Phone ____________________________________________________________ 

Address___________________________________________________________________

City_________________________________________ State_____Zip ________________

Email _____________________________________________________________________

Emergency Contact _________________________________________________________

Relationship________________________________________________________________

Phone_____________________________________________________________________

Explain any difficulties you have with __Ears   __ Neck   __Knees  

__Back   ___Joints  __Blood Pressure  __Heart   ___ Lungs  

Explanation ________________________________________________________________

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Pschological Conditions and Medications:

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Liability Waiver

I attest that am participating in this hypnosis session of my own free will, that I am of sound mind, and do not have any physical or psychological condition that would make participating in hypnosis dangerous to my well-being.  I understand that during the entire session I am in complete control and can come out of the hypnotic state anytime I choose. 

I certify that I have disclosed all relevant health problems to Living Room Yoga prior to participating in the hypnosis session.  I agree to take responsibility for my own safety by coming out of the hypnotic state should I have an experience that is not positive for me.  I acknowledge that Stacy Renz has not and will not render medical hypnosis without a health practitioner referral and has not and will not render a medical diagnosis.  I specifically agree that neither Living Room Yoga nor Stacy Renz shall not be liable for any claim, demand, cause of action of any kind whatsoever for, or on the account of death, personal injury, property damage or loss of any kind resulting from or related to my use of equipment or participation in hypnosis on the premises of Living Room Yoga.  I agree to hold Living Room Yoga harmless from same. 

I have read the above release and waiver of liability and fully understand its contents.  I signify by signing below that I voluntarily agree to the terms and conditions stated above from this date forward in all my dealings with Living Room Yoga.

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Signature                                                                                 Date

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Printed Name

FOR PRIVATE CLIENTS:  Living Room Yoga’s Cancellation Policy states that to avoid being charged for your private session, you must cancel by noon the previous business day (Monday clients must cancel by noon Saturday).  By signing below you acknowledge this policy:

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Signature                                                                                             Date