Occupation
|
SERVICES (Please Check) * |
Personal Injury Accident Treatments |
Normatec Compression |
Sports Massage Therapy |
Deep Tissue Massage |
Stretch Therapy |
Hypervolt Percussive Therapy |
Migraine Relief / Scalp Massage
|
Personal Training (1:1) |
Dance Fitness (1:1) |
Stress level*
|
Stress source (select all that apply)*
|
|
If yes, please list name and reason for medications
|
|
If yes, please list names and reason/treatment
|
Please review this list and check those conditions that have affected your health either recently or in the past. Place a check mark next to the condition. |
arthritis |
depression, panic disorder, other psych condition |
diabetes |
diverticulitis |
blood clots |
headaches |
broken/dislocated bones |
heart conditions |
bruise easily |
back problems |
cancer |
high blood pressure |
chronic pain |
insomnia |
constipation/diarrhea |
muscle strain/sprain |
auto-immune condition |
pregnancy |
hepatitis (A, B, C, other) |
scoliosis |
skin conditions |
seizures |
stroke |
whiplash |
surgery |
chemical dependency (alcohol, drugs) |
TMJ disorder |
Do you have any injuries or past surgeries? If yes, please explain *
|
Do you have any of the following today: * |
skin rash |
cold/flu |
open cuts |
severe pain |
acute infectious disease |
injuries/bruises |
fever |
None |
Do you have any allergies to: * |
skin care products |
medications |
foods (nuts, etc.) |
environmental allergens (dust, pollen, fragrances) |
None |
If any of the above are checked, please give details:
|
Where are you currently feeling discomfort? *
|
What are your expectations and goals for your session?
|
- I agree and consent to the following:I am voluntarily participating in the TerryFit services offered above. I recognize that the services may cause unlikely physical injury and I am fully aware of the risks and hazards involved.
- Being that Recovery services should not be done under certain medical conditions, I affirm that I have answered all questions pertaining to medical conditions truthfully.
- I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the above mentioned program or service. I represent and warrant that I have no medical condition that would prevent my participation in any TerryFit service.
- I agree to assume full responsibility for any risks, injuries or damage known or unknown which I might incur as a result of participating in any TerryFit services.
- I knowingly, voluntarily and expressly waive any claim I may have against the TerryFit Recovery, its employees and owners, and its affiliates for injury or damages that I may sustain as a result of participating in TerryFit services.
- I, my heirs or representatives forever release waive, discharge and covenant not to sue TerryFit Recovery, its employees, owners, and affiliates for any adverse reactions caused by any and all TerryFit services entered into.
- I have read the above waiver and release of liability, and fully understand the contents. I voluntarily agree to the terms and conditions stated above.
|
COVID 19 Release
|
I agree to the Following * |
I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above WITHIN THE LAST 14 DAYS. |
I affirm that I, as well as all household members, have not been diagnosed with COVID-19 WITHIN THE PAST 30 DAYS. |
I affirm that I, as well as all household members, have not traveled outside of the country, or to any city considered to be a "hot spot" for COVID-19 infections WITHIN THE PAST 30 DAYS. |
I understand that TerryFit Recovery, its employees, owners, and affiliates, cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client. |
TerryFit Recovery is following these enhanced procedures to prevent the spread of COVID-19 & other Viruses:
Prepayment for services available if clients prefer contactless checkout (Insurance, Venmo, CashApp, Square, Zelle)
Additional time included between appointments to prevent guest contact with each other.
Each guest is required to wash hands upon arrival.
Your Therapist will thoroughly clean hands for all consultations and treatments.
By signing below, I agree to each statement above and release Kristen Terry and TerryFit Recovery from any and all liability for the unintentional exposure or harm due to COVID-19 or other viruses. TerryFit is not liable for any injuries that may occur during treatment from patient's unknown prior medical predispositions.
TerryFit Recovery, its employees, affiliates, and owners agrees to abide by these standards and affirms the same. *
|