New Client Form

Liability Release and Client Consent to Service

Please be aware that Natural Back Pain Relief LLC is not a medical facility. A medical diagnosis will NOT be made, and we cannot accept or bill your insurance.

Client is responsible for correctly performing exercises given to them by Natural Back Pain Relief LLC. If any pain results during an exercise, client should stop and contact Natural Back Pain Relief LLC for an updated list of exercises (menu) or clarification on how to correctly perform the exercise. If new pain results after completing a menu, client is responsible for giving that feedback to Natural Back Pain Relief LLC before attempting the full menu again.

Payment of applicable fees is due in advance or at the time of your therapy session by credit card, check or cash. 

Cancelation or rescheduling must be done more than 24 hours in advance of your appointment, else you will be charged for a full session.

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Multimedia & Publicity Privacy Release (Optional)

I hereby grant Natural Back Pain Relief LLC, hereinafter referred to as the "NBPR", permission to use, reproduce, distribute, publicly perform and display, in any form now known or later developed, the items described below, hereinafter referred to as the "Materials."

I understand that I am being asked to sign this release for the purpose of NBPR advertising and promoting NBPR's business. I understand that NBPR may use the Materials on NBPR's website, social media pages, in printed materials, or for other purposes.

I release NBPR, as well as its agents, employees, owners, investors, licensees, and assigns from all claims I may have now or in the future for invasion of privacy, right of publicity, copyright infringement, defamation, or any other cause of action arising out of the use, reproduction, adaptation, distribution, broadcast, performance, or display of the Materials.

I waive any right to inspect or approve any works that may be created containing the Materials. I understand and agree that NBPR is and shall be the exclusive owner of all right, title, and interest, including copyright, in the Materials, and any advertising or promotional materials containing the Materials released hereunder.

I have fully read this release and understand that signing this release is voluntary and not a condition of service. I am fully familiar with its contents, and hereby agree to the terms above.