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Do you Smoke?*

Do you Drink? *

Do you take prescription medication(s)?*

Do you have back, knee or shoulder pain?*

Do you have previous injuries or surgeries?*

Do you have high blood pressure or blood clots?*

Do you have asthma, diabetes, or a heart condition? *

Do you have any other health conditions not listed?*

If yes to any of the above conditions, please describe:

Waiver and Release of Liability:
I affirm that I alone am responsible to decide whether to practice hypnosis and meditation during the Program. I hereby agree to release and waive any claims that I have now or hereafter may have against Mira Kelley, her associates and employees.

I assume the risk of any physical activity and release Mira Kelley, her associates, employees and any other participants in the Program from any and against all claims, actions, demands, proceedings, liabilities, cost and expenses, including reasonable attorney’s fees, which may have been ascertained against or incurred by me arising as a result of my participation in the Program. I affirm that I alone am responsible to decide whether to participate in any physical activities while in their Program. I hereby agree to release and waive any claims that I have now or hereafter may have against Mira Kelley, her associates and employees.
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