New Client Form

Client Intake and Liability Waiver
(updated with COVID-19 information)

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Email/Phone is used for communication and appointment verifications and is automated in the scheduling software. I occasional send out a Newsletter and promos to clients. I do not sell your info nor send spam and you can unsubscribe from the promo's and Newsletters at any time.

Date Of Birth *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Emergency Contact Name, Relationship, Contact Number *

How did you hear about this? *

Please identify Other and/or Referral: *

Are you under the care of a physician? *

Yes No

If Yes - Please explain and clarify if you have any other medical conditions, major accidents, injuries or surgeries your provider should know about? *

Have you ever had an Assisted Stretch Session done before? *

Yes No

If Yes - What kind? How Often? Results? *

What do you expect from your session? *

Are you or do you think you are Pregnant? *

Yes No Maybe

Do you have any head/neck concerns such as Headaches/Migraines, Ringing in ears, Vertigo/Dizziness, vision or hearing loss, etc.? *

Yes No

If Yes - Please explain. *

Do you suffer from any neurological disorders such as seizures, epilepsy, Parkinson's, MS, neuropathy/numbness, sciatica, or any sensory loss? *

Yes No

If Yes - Please explain. *

Do you have any musculoskeletal disorders such as Arthritis, Osteoporosis, Bursitis, Tendonitis, Jaw Pain, Pins/Plates/Wires or any artificial joints? *

Yes No

If Yes - Please explain. *

Do you suffer any Respiratory or Cardiovascular issues such as Asthma, Cough, shortness of breath, sinusitis, emphysema, smoker, High or Low Blood Pressure, Stroke, Heart Disease, pacemaker, hemophilia, Phlebitis/varicose veins, etc? *

Yes No

If Yes - Please explain. *

Please advise if you have any skin disorders or potential infectious health issues or have been exposed to poison ivy etc. *

Please advise if you have any other conditions such as Cancer, Depression, Fibromyalgia, Chronic Fatigue, etc *

Are you Diabetic? *

Yes No

If Yes - Is it under control? Any loss of sensation or mobility? Please explain: *

How active or sedentary are you? *

Are you in or do you have significant discomfort? Please describe WHERE you have discomfort; WHAT type of discomfort you have (dull, sharp, radiating, numbness, tingling, etc.) and HOW severe is the discomfort (using scale of 1 to 10 with 10 being the most severe - having to go to ER) *

Do you have any allergies to lotions, oils, creams, waxes, or pet fur? *

Yes No

If Yes - Please explain. *

I understand that assistive stretching / Fascia Stretch Therapy / FST is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation, assist in greater stretch gains of range of motion and energy flow. *

Yes

If I experience pain/discomfort during the session, I will immediately inform my therapist so that pressure can be adjusted to my level of comfort. I will not hold my therapist liable should I choose to not say anything if I have pain/discomfort. *

Yes

I have notified my therapist of all known medical conditions. I agree to inform my practitioner of any changes in my health and medical condition. I understand that there shall be no liability on the therapists part should I forget to do so. *

Yes

I understand that assisted stretching / FST sessions are non-sexual in nature. For other modalities, such as use of the massage gun, Far Infrared Heat and the HigherDose Sauna Blanket are available and used during session over clothing or require you to have full coverage for safety and this will be discussed prior to your session. Services are strictly professional. *

Yes

I understand that there is a 24-hour cancellation policy. If I am unable to cancel before that time I will be responsible for the costs associated with that session and may be required to pay prior to any additional sessions. *

Yes

I understand that if I have purchased a package deal, my missed or late cancelation will be counted as one of the sessions. If I arrive late to my appointment, only the allotted time remaining will be utilzed and I'm responsible for the full payment. *

Yes

I understand that the services offered today are not a substitute for medical care nor a substitute for any medical examination or diagnosis and services are not billable to my insurance. *

Yes

I understand that my provider is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness. *

Yes

By signing this release, I hereby waive and release my provider from any and all liability, past, present, and future, whether in person or virtual/online, relating to assistive stretching / Fascia Stretch Therapy / FST or HigherDose Sauna blanket sessions. I am also choosing to come in for my appointment and will not attend if I feel that my health is at risk or am a risk to others. Cancelation fees are waived and packages will be extended for Covid and other contagious diseases or outbreaks that may impact the health and safety of anyone. We are committed to providing a safe and comfortable place and environment for everyone regardless of orientation. However, sexual advances, innuendoes, or inappropriate touching will not be tolerated and will be grounds for reporting and termination of session. (Please Type in Your Name) *

I am over the age of 18. If the answer is No - you MUST be accompanied by an adult for in person sessions. *

Yes No

Any last minute thoughts, questions or concerns? *

Client Intake and Liability Waiver(updated with COVID-19 information)

Client Intake and Liability Waiver
(updated with COVID-19 information)