Reviving Fire Waiver

Client Legal Name: *

First Name Last Name

Affirming or Preferred Name:

First Name Last Name

Email Address: *

example@example.com

Phone Number: *

Area Code Phone Number

Date: *

Age: *

Gender Identity:

Woman Man Non-binary Genderqueer Genderfluid

Pronoun(s):

She/Her/Hers They/Them/Theirs He/Him/His

Gua Sha Contraindications: ( gua sha cannot be done over an opened wound, unhealed burn, moles, or a surgery site that isn't healed yet)

	Yes	No	Not Sure
After Surgery
Over burns, moles, or open wounds

Herbal Compresses:

	Yes	No	Not Sure
Multiple Sclerosis
Sensitive to Heat/Lupus/MS
Open Wounds ( avoid using the compress on an open wound)
Are you pregnant? If so only use the prenatal herbal compresses.
Do you have an aversion to heat? If so only use the cooling herbal compresses.

Herbal Steam Sauna Hard Contraindications:

	Yes	No	Not Sure
Pregnancy
Heart Disease
Fever

Hard Contraindications means that if you have a "yes" response you cannot get inside the herbal steam sauna.

Herbal Steam Sauna Soft Contraindications:

	Yes	No	Not Sure
Hyper/Hypotension
Medications
Blood thinners
Extreme heat sensitivity
Strong aversion to heat

Soft Contraindications means that if you have a "yes" response, you must consult your Doctor before getting inside the herbal steam sauna. You may also need to do shorter steaming rounds.

Contraindications for Abdominal Moxibustion Therapy:

	Yes	No	Not sure
Hot Flashes
Nightsweats
Infections
Fever
Aversion to Heat
Neon Red Menses
Purple Menses with heavy fast flow

Client Notes: Please note any medications you are taking or any known allergies you have:

Practitioner Notes:

By signing below, I understand that Laura Durbin is not a licensed medical doctor and does not diagnose, treat, cure, or prescribe. I understand that herbal, dietary, and lifestyle recommendations I receive are traditionally considered safe. I assume all responsibility for decisions I make regarding my health. I understand that if I experience any pain or discomfort during my session(s), I will immediately inform the practitioner so that the therapy can be adjusted to my level of comfort. I further understand that bodywork, herbal recommendations, steaming, or lifestyle recommendations should not be considered a substitute for medical examination, diagnosis, or treatment. I should see a qualified medical specialist for any mental or physical ailments that I experience. I understand that herbalists and bodyworkers are not qualified to diagnose or treat physical or mental illness or prescribe any medications. Nothing said during a session should be interpreted as such. Since bodywork, steaming, moxibustion therapy, and herbalism should not be practiced under certain medical conditions, I affirm that I have stated all of my known medical conditions, and I have answered all questions honestly. I agree to keep the practitioner updated to any changes in my medical profile, and I understand that there should be no liability on the practitioner's part if I forget to do so. I understand that if the steam is too hot I could get burned or that I could have an allergic reaction to herbs, oils, liniments, balms, and herbal compresses. I understand that there is a risk of unknown reactions and injuries that can occur during bodywork, that emotional releases/ reactions can occur, and that I may experience detox symptoms and get a headache. During a session, I will inform my practitioner if I wish for treatment to be stopped.

I understand that services provided by Laura Durbin, Reviving Fire, LLC, trading as Reviving Fire are strictly non-sexual. Lewd or sexual language or behavior will not be tolerated and will result in the immediate termination of the session or service and removal off of the premises or event. I also understand that I will still be responsible for full payment of the session and will not be able to make future appointments at Reviving Fire or with Laura Durbin.

Reviving Fire: Cancellation Policy:

I understand that there is a 24 hour cancellation policy for solo and group sessions. For cancellations made after the deadline, I am responsible for full payment of my session. I understand that cancellations may be made over the phone, text message, or via voicemail. Group events and woorkshops are non-refundable.

If I am late to my appointment or event I may not receive the full allotted time of my session or may not be permitted entry into the event. I understand that I am still responsible for full payment of the session/event.

As a postpartum doula, I am on call 24/7. In the case that I get called to a postpartum emergency and need to reschedule your session, I will contact you as soon as possible to reschedule.

Signature: *

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