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Please describe your interest in Vagus Nerve (VN) Rebalancing
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Do you have any of the following symptoms?
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Stress / Anxiety
Headache or facial pain
Vertigo or dizziness
Postural Hypotension/Lightheaded with stance
Heart racing or rhythm concerns
Shortness of breath
Reflux or digestive upset
Constipation / Diarrhea
Urinary urgency / other concerns
Other
Please explain above or any additional concerns you have regarding how your body responds to stress
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Please provide a brief, general medical history, including surgeries, injuries, and medication use
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I hereby agree to the following liability waiver:
1. I am agreeing to coaching services where I will participate in wellness interventions and may participate in movement and wellness practices. I recognize and am aware of the risk of injury inherent therein.
2. I am participating in these coaching services for wellness purposes, and that these services are adjunct to general medical intervention and assessment. I contend that it is my responsibility to consult with my physician regarding my participation if indicated. I represent that I have no medical condition that would prevent safe participation in these services.
3. In agreement for participation, I assume full responsibility of any risk, injury or damage, known or unknown, now or in the future, that may incur as a result of participation in LifeDance coaching services, activities, or movements, and waive any claim I may have against LifeDance or Susan Thompson-Brown, MPT, DPT, RYT, now and in the future.
4. I agree to inform Susan Thompson-Brown, MPT, DPT, RYT of any change in medical status that may affect my participation in these services.
I have read the above liability waiver, understand the conditions, and agree to terms specified. By submitting this form, I am voluntarily signing this agreement as a digital signature, which serves as complete and unconditional release of all liability.
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