Consultation & Release of Liability Form

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Name *

First

Last

Layout

Phone *

Date of Birth *

Email *

Occupation

Have you had hijama before?

If yes, when was your last session? *

Have you had any injuries?

If yes, please list? *

Are you on any medications? *

If yes, please list medication? *

Have you ever been effected by black magic (sehr) or jinn?* *

Yes
No
Not sure

Gender *

Male
Female

Are you pregnant? *

Do you smoke?

Do you drink?

Please indicate if any of the following apply to you.

Cancer
Headaches/migraines
Diabetes
High/Low Blood Pressure
Sinus
Stroke
Kidney Dysfunction
Shortness of breath
Erectile Dysfunction
Digestive Problems
Asthma
Stress
Depression
Insomnia
Stiffness or pain in joints or muscles
Arthritis
Joint Replacement
Allergies
Nerve pain
Heart Attack
Liver Dysfunction
Chest pain or tightness
Sprains/Strains
Glaucoma
Skin disorders
Anxiety
Inflammation
Do you work at a computer?
Other

If other selected, please explain: *

List areas of discomfort and pain:

What would you like to achieve from your appointment? (Specific areas of concern, back pain, depression...etc)

Is there any other information you would like to share that may benefit your hijama session?

How did you hear about us? *

Referral
Google Maps
Google Search
Facebook
Flyer in masjid
Other

Please specify here... *

WHEREAS, The Parties to this Agreement share the belief in individuals’ right to choose their healthcare and wellness services, protected under the U.S. Constitution, California Health Freedom Legislation (Senate Bill-577, 2002), and the right to religious beliefs and practices.

Disclaimer
We are not liable for any adverse health effects resulting from the use of our Hijama therapy services. Results may vary as it is a spiritual practice.

Nature of Hijama:
Hijama is a holistic, spiritual practice rooted in ancient traditions, not conventional medicine. We do not diagnose, treat diseases, or promise specific outcomes.

Individual Responsibility:
Clients are responsible for their health. Seek medical care if needed. We do not guarantee absence of adverse effects.

Release of Liability:
Clients acknowledge and accept all risks associated with our services, releasing us from any liability for loss, damage, or injury, whether occurring during or after treatment.

No Guarantees:
We do not guarantee therapy success.

Limitation of Recovery:
Legal recovery is limited to actual expenses unless negligence is proven.

By scheduling Hijama therapy, clients agree to these terms.

Date *

Signature *

Clear Signature

Consultation & Release of Liability Form

WHEREAS, The Parties to this Agreement share the belief in individuals’ right to choose their healthcare and wellness services, protected under the U.S. Constitution, California Health Freedom Legislation (Senate Bill-577, 2002), and the right to religious beliefs and practices.

📢 Notice:

Appointment Update

Thank you for visiting Bay Area Hijama. We are currently traveling and not accepting appointments until July 1st, 2026, inshAllah.

You may still use the booking calendar to schedule appointments for July 1st and onward.

We appreciate your patience and continued support.

— Bay Area Hijama