Cancellation Policy: *

Barring sickness or emergency, late cancellations (less than 24 hours) will be responsible for 50% of scheduled service fee. No shows are responsible for full scheduled service fee.

I agree.

Payment Policies: *

Payment is due in total at the time of service. Cash, check, or Venmo are accepted. If payment is not received in full at time of service, future service will be denied until such a time as payment has been rendered.

I agree.

Consent to Therapy: *

I understand and acknowledge that Brittany M Wildfong is not a diagnosing medical professional or psychotherapist. I affirm that I have notified Brittany of all known medical conditions or physical injuries I have and medications I am taking. I will inform Brittany of any changes in my health or medical conditions. I acknowledge that I do not have any injuries or medical conditions that would prevent or interfere with therapy. I understand and acknowledge that there are some risks associated with manual therapy that include, but are not limited to: muscle soreness, detoxification symptoms, and/or exacerbation of an undiscovered injury. By signing below, I release Brittany M Wildfong from any liability or responsibility for any known risks described above or other foreseeable personal injury that may arise from their service.

I agree.

Name of Patient *

Please enter patient's legal name as a signature.

First Name

Last Name

Name of Parent or Guardian

Please enter parent or guardian's legal name as a signature, if patient is under the age of 18 at time of initial visit.

First Name

Last Name