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TerryFit Intake Form

Intake Form - CONFIDENTIAL INFORMATION

WELCOME! We would like to make your appointment as pleasant and comfortable as possible. If at any time you have questions regarding your session, please let us know. 

Today's Date: November 22, 2019

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Occupation
Services interested in doing (Please Check) *
Sports Massage Therapy (50 minute session)
FST-Fascial Stretch Therapy (50 minute session)
Normatec Compression
VelaShape III (You will be receive an additional waiver to complete)
Paraffin Wax
Personal Training
Dance Fitness
Hand Therapy (50 minute session)
Stress level
Stress source (select all that apply)
Are you currently taking any medications?*
No
Yes

If yes, please list name and reason for medications
Are you currently seeing a health care professional?*
No
Yes

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

If any of the above needs to be detailed or if there is anything else to share,
Do you have any of the following today:
skin rash
cold/flu
open cuts
severe pain
acute infectious disease
injuries/bruises
fever
Do you have any allergies to:
skin care products
medications
foods (nuts, etc.)
environmental allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
contact lenses
hearing aid

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, or Kristen Terry 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 or Kristen Terry 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. 

First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

Occupation
Services interested in doing (Please Check) *
Sports Massage Therapy (50 minute session)
FST-Fascial Stretch Therapy (50 minute session)
Normatec Compression
VelaShape III (You will be receive an additional waiver to complete)
Paraffin Wax
Personal Training
Dance Fitness
Hand Therapy (50 minute session)
Stress level
Stress source (select all that apply)
Are you currently taking any medications?*
No
Yes

If yes, please list name and reason for medications
Are you currently seeing a health care professional?*
No
Yes

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

If any of the above needs to be detailed or if there is anything else to share,
Do you have any of the following today:
skin rash
cold/flu
open cuts
severe pain
acute infectious disease
injuries/bruises
fever
Do you have any allergies to:
skin care products
medications
foods (nuts, etc.)
environmental allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
contact lenses
hearing aid

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, or Kristen Terry 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 or Kristen Terry 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. 

Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

Occupation
Services interested in doing (Please Check) *
Sports Massage Therapy (50 minute session)
FST-Fascial Stretch Therapy (50 minute session)
Normatec Compression
VelaShape III (You will be receive an additional waiver to complete)
Paraffin Wax
Personal Training
Dance Fitness
Hand Therapy (50 minute session)
Stress level
Stress source (select all that apply)
Are you currently taking any medications?*
No
Yes

If yes, please list name and reason for medications
Are you currently seeing a health care professional?*
No
Yes

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

If any of the above needs to be detailed or if there is anything else to share,
Do you have any of the following today:
skin rash
cold/flu
open cuts
severe pain
acute infectious disease
injuries/bruises
fever
Do you have any allergies to:
skin care products
medications
foods (nuts, etc.)
environmental allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
contact lenses
hearing aid

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, or Kristen Terry 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 or Kristen Terry 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. 

Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

Occupation
Services interested in doing (Please Check) *
Sports Massage Therapy (50 minute session)
FST-Fascial Stretch Therapy (50 minute session)
Normatec Compression
VelaShape III (You will be receive an additional waiver to complete)
Paraffin Wax
Personal Training
Dance Fitness
Hand Therapy (50 minute session)
Stress level
Stress source (select all that apply)
Are you currently taking any medications?*
No
Yes

If yes, please list name and reason for medications
Are you currently seeing a health care professional?*
No
Yes

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

If any of the above needs to be detailed or if there is anything else to share,
Do you have any of the following today:
skin rash
cold/flu
open cuts
severe pain
acute infectious disease
injuries/bruises
fever
Do you have any allergies to:
skin care products
medications
foods (nuts, etc.)
environmental allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
contact lenses
hearing aid

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, or Kristen Terry 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 or Kristen Terry 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. 

Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

Occupation
Services interested in doing (Please Check) *
Sports Massage Therapy (50 minute session)
FST-Fascial Stretch Therapy (50 minute session)
Normatec Compression
VelaShape III (You will be receive an additional waiver to complete)
Paraffin Wax
Personal Training
Dance Fitness
Hand Therapy (50 minute session)
Stress level
Stress source (select all that apply)
Are you currently taking any medications?*
No
Yes

If yes, please list name and reason for medications
Are you currently seeing a health care professional?*
No
Yes

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

If any of the above needs to be detailed or if there is anything else to share,
Do you have any of the following today:
skin rash
cold/flu
open cuts
severe pain
acute infectious disease
injuries/bruises
fever
Do you have any allergies to:
skin care products
medications
foods (nuts, etc.)
environmental allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
contact lenses
hearing aid

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, or Kristen Terry 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 or Kristen Terry 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. 

Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

Occupation
Services interested in doing (Please Check) *
Sports Massage Therapy (50 minute session)
FST-Fascial Stretch Therapy (50 minute session)
Normatec Compression
VelaShape III (You will be receive an additional waiver to complete)
Paraffin Wax
Personal Training
Dance Fitness
Hand Therapy (50 minute session)
Stress level
Stress source (select all that apply)
Are you currently taking any medications?*
No
Yes

If yes, please list name and reason for medications
Are you currently seeing a health care professional?*
No
Yes

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

If any of the above needs to be detailed or if there is anything else to share,
Do you have any of the following today:
skin rash
cold/flu
open cuts
severe pain
acute infectious disease
injuries/bruises
fever
Do you have any allergies to:
skin care products
medications
foods (nuts, etc.)
environmental allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
contact lenses
hearing aid

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, or Kristen Terry 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 or Kristen Terry 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. 

Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

Occupation
Services interested in doing (Please Check) *
Sports Massage Therapy (50 minute session)
FST-Fascial Stretch Therapy (50 minute session)
Normatec Compression
VelaShape III (You will be receive an additional waiver to complete)
Paraffin Wax
Personal Training
Dance Fitness
Hand Therapy (50 minute session)
Stress level
Stress source (select all that apply)
Are you currently taking any medications?*
No
Yes

If yes, please list name and reason for medications
Are you currently seeing a health care professional?*
No
Yes

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

If any of the above needs to be detailed or if there is anything else to share,
Do you have any of the following today:
skin rash
cold/flu
open cuts
severe pain
acute infectious disease
injuries/bruises
fever
Do you have any allergies to:
skin care products
medications
foods (nuts, etc.)
environmental allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
contact lenses
hearing aid

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, or Kristen Terry 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 or Kristen Terry 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. 

Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

Occupation
Services interested in doing (Please Check) *
Sports Massage Therapy (50 minute session)
FST-Fascial Stretch Therapy (50 minute session)
Normatec Compression
VelaShape III (You will be receive an additional waiver to complete)
Paraffin Wax
Personal Training
Dance Fitness
Hand Therapy (50 minute session)
Stress level
Stress source (select all that apply)
Are you currently taking any medications?*
No
Yes

If yes, please list name and reason for medications
Are you currently seeing a health care professional?*
No
Yes

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

If any of the above needs to be detailed or if there is anything else to share,
Do you have any of the following today:
skin rash
cold/flu
open cuts
severe pain
acute infectious disease
injuries/bruises
fever
Do you have any allergies to:
skin care products
medications
foods (nuts, etc.)
environmental allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
contact lenses
hearing aid

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, or Kristen Terry 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 or Kristen Terry 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. 

Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

Occupation
Services interested in doing (Please Check) *
Sports Massage Therapy (50 minute session)
FST-Fascial Stretch Therapy (50 minute session)
Normatec Compression
VelaShape III (You will be receive an additional waiver to complete)
Paraffin Wax
Personal Training
Dance Fitness
Hand Therapy (50 minute session)
Stress level
Stress source (select all that apply)
Are you currently taking any medications?*
No
Yes

If yes, please list name and reason for medications
Are you currently seeing a health care professional?*
No
Yes

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

If any of the above needs to be detailed or if there is anything else to share,
Do you have any of the following today:
skin rash
cold/flu
open cuts
severe pain
acute infectious disease
injuries/bruises
fever
Do you have any allergies to:
skin care products
medications
foods (nuts, etc.)
environmental allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
contact lenses
hearing aid

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, or Kristen Terry 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 or Kristen Terry 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. 

Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

Occupation
Services interested in doing (Please Check) *
Sports Massage Therapy (50 minute session)
FST-Fascial Stretch Therapy (50 minute session)
Normatec Compression
VelaShape III (You will be receive an additional waiver to complete)
Paraffin Wax
Personal Training
Dance Fitness
Hand Therapy (50 minute session)
Stress level
Stress source (select all that apply)
Are you currently taking any medications?*
No
Yes

If yes, please list name and reason for medications
Are you currently seeing a health care professional?*
No
Yes

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

If any of the above needs to be detailed or if there is anything else to share,
Do you have any of the following today:
skin rash
cold/flu
open cuts
severe pain
acute infectious disease
injuries/bruises
fever
Do you have any allergies to:
skin care products
medications
foods (nuts, etc.)
environmental allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
contact lenses
hearing aid

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, or Kristen Terry 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 or Kristen Terry 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. 

Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
TerryFit operates out of two convenient locations in Los Angeles.
Please select which location you will be visiting for your appointment.*
11819 Wilshire Blvd. STE 203, Los Angeles, CA 90025
1211 Montana Avenue, Santa Monica, CA 90403
Please fill out your CC information below to hold your appointment.
By completing the below details, I authorize my card to be charged for the full amount of the service in the event of a no-show or late cancellation (within 24 hours of time of service). Please be aware that there is a 3% charge for all CC transactions.*
Yes

Name as appears on card *
CC Type (Select One)*
Visa
Mastercard
Amex
Discover

Card Number *

Expiry Date (MM/YY) *

CVV Code *

Billing Address *

Billing Zip Code *

Email Address (Receipt Provided) *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Occupation
Services interested in doing (Please Check) *
Sports Massage Therapy (50 minute session)
FST-Fascial Stretch Therapy (50 minute session)
Normatec Compression
VelaShape III (You will be receive an additional waiver to complete)
Paraffin Wax
Personal Training
Dance Fitness
Hand Therapy (50 minute session)
Stress level
Stress source (select all that apply)
Are you currently taking any medications?*
No
Yes

If yes, please list name and reason for medications
Are you currently seeing a health care professional?*
No
Yes

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

If any of the above needs to be detailed or if there is anything else to share,
Do you have any of the following today:
skin rash
cold/flu
open cuts
severe pain
acute infectious disease
injuries/bruises
fever
Do you have any allergies to:
skin care products
medications
foods (nuts, etc.)
environmental allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
contact lenses
hearing aid

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, or Kristen Terry 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 or Kristen Terry 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. 

Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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