Sports Massage Intake Form - The Fountain Spa

Name

Phone Number

ZIP

Please list any recent injuries, illnesses, or surgeries:

Purpose

Do you have any chronic or frequent pain?

Are you pregnant?

Have you received a Stretch Therapy Session before?

I understand that facilitated stretch therapy (FST) is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation, range of motion and energy flow.

If I experience pain or discomfort during the session, I will immediately inform my practitioner so that pressure can be adjusted to my level of comfort. I will not hold my practitioner responsible for any pain or discomfort I experience during or after the session.

I affirm that I have notified my practitioner of all known medical conditions and injuries.

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 instructor’s part should I forget to do so.

I understand that stretch therapy sessions are designed to assist in greater stretch gains and are non-sexual in nature.

I agree that this is NOT considered Physical Therapy

I understand that the services offered today are not a substitute for medical care. I understand that my practitioner is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.

By signing (checking) this release, I hereby waive and release my practitioner from any and all liability, past, present, and future relating to these fascial stretch sessions/bodywork. I have read and agree to these policies therein.

Information and Suggestions • Prior to your stretch, please remove jewelry or watches. • Pull long hair back with a clip or band. • Please wear loose, long, comfortable clothing that allow for freedom of movement. • Feel free to ask your practitioner any questions before, during, or after the session.