Intake Form - Relaxation By Stretch

Name *

First

Last

Email *

Phone Number

Occupation

Family Doctor

How did you hear about us?

Website
Social Media
Friends
Others

I certify that I am a healthy and do not show any symptoms of influenza, COVID-19 or similar illnesses. Including: cough, runny nose, shortness of breath, loss of smell/taste, high fever or body chills. (if these symptoms are present please contact us to reschedule your appointment) *

Yes
No (please reschedule for another time)

Have you received Stretch Therapy before?

Are you working through an injury right now? *

If Yes, List any injuries you have or have had in the past.

Have you had any surgeries? *

If Yes – Please briefly explain.

Please list any physical activities you do regularly and/or enjoy…

What is your overall goal or intention in coming to work with us? *

Do you experience any of the following symptoms currently or in the last 6 months? *

If you answered “Yes” to any of the options above, please explain.

If you answered "Yes" to any of the options above, please explain.

Has a health care provider told you that you should avoid or modify certain types of physical activity? *

If Yes, please explain.

Do you have any other medical or physical condition (such as diabetes, cancer, osteoporosis, asthma, spinal cord injury) that may affect your ability to be physically active? *

If Yes, please explain.

Accuracy of Information *

I certify that the above medical information is correct to my knowledge.

Privacy and Sharing of Information *

I agree

I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.

Cancellation Policy *

I am aware of the Cancellation Policy

Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the therapists’ day that could have been filled by another patient. As such, we require 24 hours notice for any cancellations or changes to your appointment. Patients who provide less than 24 hours notice, or miss their appointment, will be charged a cancellation fee.

Liability Waiver *

I agree

I understand that Relaxation By Stretch is provided for relaxation, relief from muscular tension, stress relief, and improvement of circulation, range of motion and energy flow. I understand the risks involved in undertaking stretching/personal training and/or Breathwork techniques. I understand that this is movement based therapy and may include some movements that my body is not familiar or practiced with. If I experience pain or discomfort during the session, I will immediately inform my practitioner so he/she can adjust the work to my level of comfort. I will not hold my practitioner responsible for any pain or discomfort I experience during or after the session. Some sensations that may be felt during Breathwork may include lightheadedness, tingling, stiffness, and dizziness. These sensations are not necessarily bad, but may be surprising to those new to breathwork. I affirm that I have notified my practitioner of all known medical conditions and physical injuries, and agree to notify them of any changes that may occur over time. I understand that the services offered today are not a substitute for medical care. We reserve the right to refuse treating a client if we deem that client is unfit for the treatment/session due to serious illness or injury. A doctor’s note may be required for ongoing treatment for clients in certain conditions. By signing this release, I hereby waive and release my practitioner from any and all liability, past, present, and future relating to FST/bodywork/breathwork/personal training sessions.

Date