For Jai Dee
221 1st Ave NE│Osseo, Minnesota 55369
612.810.6848│www.chooseyourself.com │info@chooseyourself.com
-Please fill out the form completely and correctly.
-Form submission is needed before the appointment.
-Please read the information thoroughly before you fill in your details.
By filling the form you agree to Jai Dee’s terms and conditions. Please contact us for any queries.
I release Jai Dee and its owners, employees, and agents, and will hold them harmless from any and all liability arising out of any personal injuries or damages, foreseeable or unforeseeable, which may occur in the ordinary course of my participation in yoga, wellness activities, and use of Jai Dee facilities. Specifically, I release Jai Dee from any and all liability occurring as a result of my participation in the practice of yoga, wellness activities, and the use of Jai Dee facilities for consideration of the use of said facilities and yoga and wellness instruction.
I make this agreement freely and voluntarily. I have had the opportunity to discuss this waiver and exculpatory terms with Jai Dee I am aware of the fact and trust I have the opportunity to negotiate the terms of this waiver prior to signing. By signing this document I declare that I was made so aware and agree to its terms.
I understand that yoga and wellness activities are recreational activities that carry inherent physical risks. I understand that Jai Dee and its instructors, no matter how well-trained and educated, cannot prevent me from any and all injury arising from the practice of yoga and wellness activities. I hereby declare that I am aware of the inherent risks of this activity and that therefore Jai Dee cannot be held liable for any injury to me occurring in the ordinary course of my participation.
I confirm to receive promotional emails/SMS which Jai Dee sends occasionally to inform about the studio, offers, and events.
I hereby declare myself physically and mentally sound and capable of participation in this activity.
Please read this Complementary and Alternative Health Care Client Bill of Rights.
I am pleased to provide you with this Client Bill of Rights, in accordance with Minnesota laws, Statute 146A, governing complementary and alternative health care practices.
Jai Dee LLC. services are available at:
233 1st Ave NE, Osseo, MN 55369
Michelle Aalbers is certified with Thai Yoga Bodywork, LLC, a Registered Thai Therapist (RTT) with the Thai Healing Alliance, and is diligent with continuing education. Additionally, Michelle Aalbers RTT has the following certifications: 500 Certified Yoga Teacher, Certified Zentangle Teacher, Chi Nei Tsang, Reiki Master Teacher, Advanced Certified Tarot Reader, Aromatherapy Level 1, Restorative Yoga, Foot Reflexology, Tok Sen, Solution Based Counseling, and Thai herbal compress.
In accordance with Minnesota state law, I am providing you with the following notice: “THE STATE OF MINNESOTA HAS NOT ADOPTED ANY EDUCATIONAL AND TRAINING STANDARDS FOR UNLICENSED COMPLEMENTARY AND ALTERNATIVE HEALTH CARE PRACTITIONERS. THIS STATEMENT OF CREDENTIALS IS FOR INFORMATION PURPOSES ONLY. UNDER MINNESOTA LAW, AN UNLICENSED COMPLEMENTARY AND ALTERNATIVE HEALTH CARE PRACTITIONER MAY NOT PROVIDE A MEDICAL DIAGNOSIS OR RECOMMEND DISCONTINUATION OF MEDICALLY PRESCRIBED TREATMENTS. IF A CLIENT DESIRES A DIAGNOSIS FROM A LICENSED PHYSICIAN, CHIROPRACTOR OR ACUPUNCTURE PRACTITIONER, OR SERVICES OF A PHYSICIAN, CHIROPRACTOR, NURSE, OSTEOPATH, PHYSICAL THERAPIST, DIETITIAN, NUTRITIONIST, ACUPUNCTURE PRACTITIONER, ATHLETIC TRAINER OR ANY OTHER TYPE OF HEALTH CARE PROVIDER, THE CLIENT MAY SEEK SUCH SERVICES AT ANY TIME.”
If you have any concerns, you may file a complaint with the following office.
Office of Complementary and Alternative Practice (OCAP)
Minnesota Department of Health
P.O. Box 64975, Suite 400 Metro Square Building
St. Paul, MN 55164
Website: www.health.state.mn.us
Fees are payable at the time of service. If you are unable to pay the full fee at the time of service, a payment plan can be arranged. This plan must be agreed to in writing prior to the provision of services. In order to receive services, you must be current with your payment plan arrangement. We do not handle insurance claims; however, a receipt will be provided to you, should you wish to file a claim with your provider. We do not accept Medicare, Medical Assistance, or General Assistance medical care.
You have the right to reasonable notice of changes in services or charges, and I will provide prior notice of any changes.
Jai Dee is committed to being a premier provider of Thai Yoga Bodywork and wellness services for the purpose of healing and well-being. We will provide a comprehensive session based on the needs and availability of the client. To the extent possible, Jai Dee will provide ongoing care as part of the client’s personal wellness program. The intention of each session is always for the client’s highest good of balancing the energies of their body, mind, and spirit.
You have the right to complete and current information concerning our assessment and recommended service, including the expected duration of the services to be provided. If you have any questions, please ask.
You may expect courteous treatment and to be free from verbal, physical, or sexual abuse by your practitioner.
Your records and transactions with this office are confidential. This information will not be released unless you authorize release in writing, or unless release is required by law.
You are allowed access to records and written information from records in accordance with section 144.335 of Minnesota Statutes.
Other similar services are available in the community. Possible sources of information are Minnesota Wellness Directory, the Edge newspaper directory, or the telephone yellow pages. You may ask your practitioner and she will provide this information to the best of her knowledge.
You have the right to choose freely among available practitioners and to change practitioners after services have begun, within the limits of health insurance, medical assistance, or other health programs. If these services are covered by your health insurance, medical assistance plan, or other health programs, you should direct all questions about coverage to your health insurance provider.
If you change practitioners, you have the right to our assistance in coordinating this transfer to another practitioner.
You are free to refuse services or treatment unless otherwise provided by law.
You may assert your rights described in this Client Bill of Rights at any time without retaliation.
ACKNOWLEDGMENT I have received a copy of the Complementary and Alternative Client Bill of Rights. I have read and understood the Client Bill of Rights, or it has otherwise been read to me. I have had a full opportunity to ask any questions I have about this document and my rights as a client. I understand my rights as a client.