Name *

First Name

Last Name

Are you under the care of a physician? *

Yes

No

Do you have any special medical needs or considerations? (i.e. use wheelchair or walker, have shortening / hardening of muscles known as a contracture, etc) *

Yes

No

Have you ever had a Fascia Stretch Therapy session, Massage, or any other type of Bodywork (even Physical Therapy, Chiro, etc.) done before? *

Yes

No

Are you or do you think you are Pregnant? *

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Do you have any skin disorders or other health infections such as Hepatitis, Herpes, HIV/AIDS, TB, Lyme disease, etc? *

Yes

No

Are you Diabetic? *

Yes

No

If Yes - Is it under control?

Yes

No

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

Yes

No

I understand that assistive stretching / Fascia Stretch Therapy / FST / massage /Myoskeletal bodywork 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 assistive stretching / Fascia Stretch Therapy / FST / massage / myoskeletal bodywork sessions are non-sexual in nature. For other modalities, such as taping, IASTM, light therapy there will be skin exposure and proper draping to ensure your privacy and to your comfort level 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. Any NO SHOW is responsible for the FULL amount and if paid in advance will not be refunded. *

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 practitioner is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness. *

Yes

I am over the age of 18. If the answer is No - you MUST be accompanied by an adult for in person sessions, and an adult over 21 MUST be present for virtual/online sessions. NO EXCEPTIONS. *

Yes

No