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Sports Massage Intake Form
Name
Phone Number
ZIP
Email
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.
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.
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 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 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 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 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.
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.
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.
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.
SUBMIT
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