I declare that I am here of my own will. The information that I have provided on this form is true and correct to the best of my knowledge, and I have not intentionally withheld any information relevant to the treatment recommended/requested. I understand that any therapy provided to me by my practitioner does not constitute medical treatment. I agree to waive all liabilities towards my therapist/Employer for any injury or damages incurred due to any misrepresentation of my health history.