Name *

First Name

Last Name

Do you currently have any of the following conditions?

Cancer or had cancer in the last 5 years

Diabetes

High/Low blood pressure

Arthritis

HIV/AIDS

Hepatitis

Skin disease

Seizure disorder

Hormone imbalance

Thyroid imbalance

Blood clotting

Liver/Kidney infection

Any active infection

Epilepsy

Fungal conditions

Heart conditions

Infectious diseases

Infectious diseases

Muscular problems

Recent cut/abrasion/bruising/swelling/inflammation

Skin disorders

Thrombosis/varicose veins

Other

Declaration: *

“I the above, have completed the form as fully and accurately as I can. I believe the details to be correct and consent to work with the practitioners within Paradox. I release the practitioner/company from any negligent misrepresentation that may be contained in the form. I accept that exercise I participate in is taken at my own risk. I understand that failure to disclose information requested above may result in adverse side effects, unknown because of this to which I accept full liability/responsibility. I am aware that it is my responsibility to inform the practitioner of my current and ongoing medical or health conditions, and it is essential for the caregiver to execute appropriate treatment procedures. I understand Paradox reserves the right to charge for appointments cancelled or broken without 24 hours notice.”

I agree to the above declaration

Date *

MM

DD

YYYY