H e l p i n g Y o u S o a r T o Y o u r P e a k P o t e n t i a l Intake Form: Best Couples Massage Program DISCLAIMER: The Best Couples Massage Program focuses on teaching massage and touch therapy practices to couples for health and wellness, and is not a substitute for medical care or treatment. Dr. David Allan is a licensed chiropractor and maintains a wellness practice with a purpose of using wellness tools like massage and healing touch to improve the quality of your life, and to improve the quality of your relationships. Dr. Allan and staff will do the very best they can teaching you and/or your partner their massage and touch protocols, but assumes no guarantees, nor responsibilities to your successes or failures. It is your responsibility to take the materials and apply them as best you can in your own life. If there is any massage or touch technique that you experience that doesn’t feel right, or causes pain or discomfort to any degree, STOP IMMEDIATELY and alert this to Dr. Allan or his staff. This too applies to any massage techniques or touch that is performed away from the class setting. In our program we include general guidelines, indications and contraindications, and safety precautions. You must adhere to all general guidelines and safety precautions. Everyone in class must be respectful of other couples and individuals attending. Any misconduct will be grounds for the removal of your membership. In the group setting, there will be no sexual advances of any kind permitted. We must be respectful for all whom are attending. Dr. Allan and staff will be held harmless and void of any responsibility for any negligence caused by you or your partner. If you perform any of the massage techniques or touch learned in class and not really sure if you and your partner is safe, then stop immediately. Your safety is our utmost concern. If you have any questions whatsoever about the application, do not hesitate to contact Dr. Allan and his staff. To help ensure safety, couples will always work with one another. All individual members that attend a class will work directly with Dr. Alan and his staff. There will be personal information divulged in class, and Dr. Alan will abide by all privacy laws and regulations that are set up in the state of California. Nothing discussed in class will be used outside the program in any regard unless a release is signed by the class participant. Dr. Allan and DAGIIT (Dr. Allen’s global Institute of integrated touch) owns the copyright to all of the material covered in the Best couples massage program. Information may be printed or videos downloaded for personal use only. The information may not otherwise be reproduced and must not be distributed or transmitted to any other person or used in any way without the expressed written approval from Dr. David Allan. Therefore, do not record any portion of the program with your cell phone, camera or other recording device. It will be necessary to RSVP for any class at the best couples massage program website. Please note that we require a 24 hour notice to cancel a RSVP. If you need to cancel a RSVP inside the 24 hours, you will be responsible for paying the entrance fees. If you do not contact us to cancel your RSVP and don’t show up for class, we will immediately suspend your membership from the group. By choosing the YES button here on this questionnaire below, you signify that you’ve read and understand this disclaimer, and agree to all the terms within. * The purpose of this form is to collect information so Dr. Allan can create a more personalized massage program for you. This form is strictly confidential, and all information collected will be kept private by Dr. Allan. It will be necessary to complete and submit this form before you start the program. I will also need your partner to fill out a separate intake too. If you have any problems submitting this form, make sure all questions with a red asterisk are answered.