DEMOR Intake Form

thank you for your submission

Do you have past or current injuries?
Do you have difficult laying on your front, back, or side?
Do you have an allergy to oils, lotions, or ointments?
Do you wear contact lenses?
Do you wear dentures?
Do you wear hearing aids?
Do you currently participate in a cardiovascular training routine?
Do you currently participate in resistance (weight) training routine?
Do you currently participate in a stretch training routine?
Do you sit at your workstation without regular timed breaks?
Do you have one or more sensations listed during movement, check all that apply?

Do you have one or more sensations while sitting, check all that apply?

Do your sensations cause you to experience, check all that apply?

Do you consistently feel stress in one or more areas of your life?

Male and female genitalia and women's breasts will not be exposed or massaged at any time. Draping will be used during the session and only the area being worked on will be uncovered.


This is a therapeutic bodywork session and any sexual remarks or advances will terminate the session immediately and you will be liable for payment of the scheduled treatment.


Draping during the session, and the working area will be uncovered. DHST bodywork session. Therefore, as a result of this, give my consent to receive DEMOR HotSpot Treatment services., and I acknowledge and agree that I am doing so at my own risk. My health and safety concerning such Services are my sole responsibility. I acknowledge that my receipt of the Services from DHST, Inc. may result in feeling painful sensations. My decision to receive Services from DHST, Inc. is voluntary, and I know of, understand, and assume all the risks associated.

 I verify that all information is correct and current to the best of my knowledge. I further understand that DEMOR HotSpot Therapy should not be construed as a substitute for medical examination, diagnosis, or treatment that should be seen by a Physician. I agree to keep the specialist updated on any changes in my medical profile and understand that there shall be no liability on the specialist part should I fail to do so. I understand that any information provided is for safety purposes and will be kept strictly confidential, except that DHST, Inc. may use such information for statistical analysis or scientific purposes.

 In exchange for receiving Services from DHST, Inc., I, for myself and on behalf of my heirs, executors, administrators, and personal representatives, as a result of this waive, release, discharge and hold harmless DHST, Inc., its members, officers, employees and agents from all liability for all injuries, including death, damages or claims relating to or resulting from my receipt of the Services, now or in the future, foreseen or unforeseen. Further, I will indemnify and hold DHST, Inc., its members, officers, agents, and employees, harmless from and against all claims, rights, damages, liabilities, losses, costs and expenses (including reasonable attorneys' fees) arising from or in connection with any injuries to other persons or damage to property caused by or attributed to me.

 I, the undersigned participant, affirm that I am of the age of 17 years or older and that I am freely signing this agreement. I certify that I have read this agreement, that I fully understand its content and that this release cannot be modified orally. I am aware that this is a release of liability and a contract and that I am signing it of my own free will

DEMOR HotSpot Therapy®

Office: (949) 861-4378
Toll Free: 1 (866) 336-6755
5001 Birch St, Newport Beach, CA 92660
Today 9:00 am – 6:00 pm

(949) 861-4378

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