Health History Form

In consideration of the safety, liability, and accountability of both the patient(s) + therapist(s), we’ve created an open-concept clinic. We ask that you either bring comfortable clothing, two piece swimsuit or flexible underpants/shorts during your treatment(s). All payment(s) must be received 48 hours prior to treatment(s) to secure your therapist(s). Free to book an appointment today!

All payment(s) must be received 48 hours prior to treatment(s) to secure your therapist(s). Free to book an appointment today!
Your Name *
Your Name
All treatments start at $100
Treatment Date *
Treatment Date
Emergency Contact Information
Emergency Contact Information
Doctor Contact Information
Doctor Contact Information
(Number of weeks)
Well Being
Neck
Please select specific area of complaints
Back
Please select specific area of complaints
Local
Please select specific area of complaints
Arms
Please select specific area of complaints
Legs
Please select specific area of complaints
Headaches
Please select specific area of complaints
Family History
Please select specific area of complaints
Musculoskeletal
Please select specific area of complaints
Neurological
Please select specific area of complaints
Skin
Please select specific area of complaints
Miscellaneous
Please select specific area of complaints
Registrants, Attendees and Readers of ActifyCity™ (hereby referred to as "Participants") of ActifyCity™ must comprehend that serious risks may be associated with physical activity of any kind including any variety of yoga, meditation, dance, pilates, crossfit, any type of physical exercise, breath work practice and participation in yoga/fitness related activities, including body massage and/or touch, Concert, Yoga Dance / dog yoga and/or any kind of activity (leashed or unleashed) / Rave attendance and participation. Participants must acknowledge such potential risks may be minor or serious and participants must attend all sessions and/or activities accepting and assuming the inherent risks associated with their participation in any activities of ActifyCity™. ActifyCity™ or its founders, employees, affiliates, associates, members, and/or volunteers, are NOT responsible for any injury, including death, to any person participating in ActifyCity™. In consideration of my acceptance and my participation in ActifyCity™, I hereby release and covenant not to sue ActifyCity™, or its founders, for any and all present and future claims resulting from ordinary negligence and inherent risk during ActifyCity™ including but not limited to, any loss, injury, damage, or liability sustained by me. Please be aware that by entering this area, you consent to your voice, name, and/or likeness being used, without compensation, in films, pictures, and tapes for exploitation in any and all media, whether now known or hereafter devised, for eternity, and you release ActifyCity™, its successors, assigns and licensee from any liability whatsoever of any nature. Do not enter this area if you do not wish to be subject to the foregoing. *
Important Notice
Due to the limited space, all applications will be reviewed and we will contact you to let you know if you have been accepted. We reserve the right to reject any business or organization.