CLICK HERE FOR IMPORTANT APPOINTMENT POLICIES

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Hypnosis
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Call us Today:

(609) 242-3900

hopehypnosis@aol.com

465 Route 9, Waretown, New Jersey 08758

Subscribe to Our Newsletter Subscribe to Mary's YouTube Channel Make a Payment SPIRITUAL JOURNEY METAPHYSICAL GIFTS

In-Person, Telephone, Virtual:

Hypnosis, Readings, Reiki Healings & Classes

Call us Today:

(609) 242-3900

hopehypnosis@aol.com

465 Route 9, Waretown, New Jersey 08758

CLICK HERE FOR IMPORTANT APPOINTMENT POLICIES

Subscribe to Our Newsletter Subscribe to Mary's YouTube Channel Make a Payment SPIRITUAL JOURNEY METAPHYSICAL GIFTS

In-Person, Telephone, Virtual:

Hypnosis, Readings, Reiki Healings & Classes

Home
Hypnosis
Energy Healing & Classes
Psychic Astrology/Angel Reading
- Monthly Horoscope
- All About Angels
Spiritual Journey Metaphysical Gifts
Forms

Forms must be filled out at time of booking with the exception of Covid-19 Waiver which must be filled out within 24 hours of appointment.

COVID-19 Liability Waiver

Date

First Name:

Last Name:

Are you currently experiencing respiratory symptoms?

Yes

Are you experiencing a fever?

Yes

Have you traveled out of NJ (excluding NY, PA, DE and CT) within the last 10 days?

Yes

IF YES, have you received your second COVID vaccine? if so, what date?

Have you had close contact with anyone that has a confirmed case of Covid-19 within the last 14 days?

Yes

IF YES, have you received your second COVID vaccine? if so, what date?

Have you EVER tested POSITIVE for Covid-19

Yes

IF YES, when?

Have you been cleared to leave home isolation?

Yes

Acknowledge

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
I further acknowledge that Hope Hypnosis & Holistic Center LLC has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
I further acknowledge that Hope Hypnosis & Holistic Center LLC can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others.
I voluntarily seek services provided by Hope Hypnosis & Holistic Center LLC and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.

I attest that:
* I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
* I have not traveled internationally within the last 14 days.
* I have not traveled to a highly impacted area within the United States of America in the last 14 days.
* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.
* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.

I hereby release and agree to hold Hope Hypnosis & Holistic Center LLC, Mary M. Silvernail & Earl L. Silvernail harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the Hope Hypnosis & Holistic Center LLC, or that may otherwise arise in any way in connection with any services received from Hope Hypnosis & Holistic Center LLC. I understand that this release discharges Hope Hypnosis & Holistic Center LLC. Mary M. Silvernail and Earl L. Silvernail from any liability or claim that I, my heirs, or any personal representatives may have against the holistic center with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Hope Hypnosis & Holistic Center LLC. This liability waiver and release extends to Hope Hypnosis Center LLC together with all owners, partners, and employees.

Signature

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Contact Information

hopehypnosis@aol.com

(609) 242-3900

465 Route 9, Waretown, New Jersey 08758

Board Certified: Intnl. Medical & Dental Hypnotherapists Assn., Intnl. Assn. Of Counselors & Therapists, American Board of Hypnotherapy.

No refunds

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