PLEASE LIST ANY INJURIES, SURGERIES, OR BROKEN BONES WITH DATES:

PLEASE CIRCLE ANY OF THE FOLLOWING CONDITIONS YOU ARE EXPERIENCING:

I understand if I experience any pain or discomfort during my session(s), I will immediately inform the practitioner. I understand that the ear candling treatment is designed to be a health aid and is no way to take the place of a doctor’s care when it is indicated. I understand the Ear Candling practitioner is not qualified to diagnose, prescribe, nor treat any physical or mental illness, and nothing said in the course of the session given should be construed as such. Because ear candling should not be done under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile, and I understand there shall be no liability on the practitioners’ part should I forget to do so. It is further understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment for the “Full” scheduled appointment.