Holt Fit Performance Recovery Center

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Do you have any allergies to latex, medications etc?

Do you do excessive workouts, If so please describe?

Reason for today’s visit - What is your main complaint and or problematic areas?

Have you had any previous injuries or surgeries? If so, list any and all?

Have you received previous sports muscle therapy?

Have received Myofascial/ Neuromuscular manipulation?

Have you had scraping "GuaSha" done before?

Have you ever had cupping done before?

Date of last massage, bodywork or sports therapy treatment?

Do you experience any of the following symptoms?

Do ANY of the following apply to you?

Do you experience any of the following Neck symptoms?

Do you experience any of the following Shoulder, Back, Hip and Leg pain?

Do you have any chronic medical conditions in which we should know about? if so list them all

I authorize and give consent to HoltFit performance recovery center to take pictures/ videos

WAIVER:
I understand that HoltFit performance recovery center LLC does not identify or diagnose any condition(s) or disease(s). Holtfit performance recovery center llc offers no treatment for any condition(s) or disease(s). We promise no cure for any disease(s) or condition(s).

I acknowledge that HoltFit performance recovery center LLC is not a substitution for medical examination or diagnosis and it is recommended that a physician be seen for that service.

Should any health condition arise while you are a client at HoltFit performance recovery center LLC, we recommend that you immediately see the appropriate healthcare provider.

At HoltFit performance recovery center LLC, any options that are rendered by the staff and/or head personnel should NEVER be construed as medical advice but merely as opinions. If you like medical advice, please see one of YOUR medical doctors. We will not deal with any medical condition at Holt Fit Bodywork & Recovery

It is my choice to receive HoltFit performance recovery center LLC as a form of recovery.

WAIVER OF ALL EQUIPMENT AND SERVICES:
I understand that all treatments and equipment such as Rapid Reboot full body compression, Infrared Red Light Dry Steam POD, Himalayan Sauna, and Cold Plunge is designed to address the care and prevention of myofascial pain and dysfunction, to encourage a state of relaxation, and to restore functional movement where possible, Should I sustain an injury while receiving treatment it is at my own risk and I agree to not hold HoltFit performance recovery center LLC responsible.

I have stated my medical conditions and health concerns are true to the best of my knowledge/ ability and will update my therapist of any changes in my health status. I understand that my failure to do so may pose a threat to my health and physical well being and I hold HoltFit performance recovery center LLC and my therapist harmless from any liability whatsoever arising from failure on my part.

PATIENT AGREEMENT:

I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained to me. My questions have been answered to my complete satisfaction. I have been urged and have been given all the time I need to read and understand.

If you have any questions regarding the risks or hazards of the proposed treatment or any questions whatsoever concerning the proposed treatment or other possible treatments, ask your doctor now before signing this consent form.

CANCELLATION POLICY:
We know your time is valuable, and ours is too. Out of respect for our staff and our other clients, we ask that you give us at least 48- hour notice if you need to cancel an appointment. Please understand that when you do not cancel or show up for an appointment, it is a cost to us.

If you are sick or not feeling well please kindly reschedule your session

If you are more than 15 minutes late please know that your session will be cut in half and or automatically rescheduled

We ask that you give us a minimum of 48 hrs cancellation notice in order to avoid being charged a late fee, please understand that when you do not cancel or not show it is a cost to us.

A $75 per person no- call/ no- show will be automatically applied if you cancel within 48 hours, A $25 same- day fee will also be applied if you cancel on the day of your scheduled appointment.

All deposits are NON- REFUNDABLE (this will be applied towards your session)

A one-time cancellation/ reschedule 24 hrs prior to appt time MUST be made, otherwise, the deposit will be forfeit

SERVICE AGREEMENT:

(1) SERVICES TO BE PROVIDED

The Office provides Sports Muscle Therapy Rapid Reboot full body compression, Infrared Red Light Dry Steam POD, Himalayan Sauna, and Cold Plunge

(2) PAYMENT

Payment in full is to be made prior to the start of any program at HoltFit performance recovery center LLC

(3) CLIENT COOPERATION

This Agreement contemplates full Client cooperation in the course of services agreed upon. This cooperation includes the Client’s agreement to remain active in the recommended program for all service visits. The Client recognizes that compliance with recommended services and service schedule is important and the Client agrees to follow the service plan and the course of treatment agreed upon.

(4) TERMINATION

The Client may discontinue care and terminate this Agreement at any time by written notice to that effect delivered in person, or by mail, to the office. Such “notice of termination” shall discharge the office from all further obligations and/or duty to render care to the client. The office reserves the right to terminate this Agreement in its sole discretion notwithstanding any other terms or provisions of this Agreement.

(5) RELEASE OF LIABILITY:

The client agrees to indemnify, hold harmless, and release at HoltFit performance recovery center LLC its agents, employees, officers, directors, representatives, assigns, members, affiliated organizations, and insurers, and others acting on the Company’s behalf, of all claims, demands, causes of action, and legal liability, whether the same be known or unknown, anticipated or unanticipated, and further agrees that except in the events of the Company’s gross negligence or willful and wanton misconduct, no claims, demands, legal actions and causes of action, shall be made against the Company for any economic and non-economic losses of any kind.

(6) YOUR RESPONSIBILITIES:

1. Keep your appointments. We require 48-hour advance notice to reschedule/cancel an appointment.

2. Cupping bruises can last anywhere from a few weeks to a month leaving scar-like marks, however, there are times where it may last longer depending on your " Chi Flow and toxin build-up" and in rare cases may cause blistering due to stagnant blood as well. Scraping marks normally last several days, it may even look bruised however will disappear over time.

3. If you have any challenges whatsoever, please share them with us immediately. Remember, it is in both our interests for you to succeed in achieving your goals.

4. If you have any medical conditions, please share this program with your physician immediately. HoltFit performance recovery center LLC is not a medical facility and does not make medical decisions.

(7) GOVERNING LAW

HoltFit performance recovery center LLC. This Agreement shall be governed, construed, and interpreted by, through, and under the Laws of the State of HAWAII.

(8) COMPLETE AGREEMENT

This Agreement constitutes the complete agreement and understanding between Client and Office and will not be changed or modified in any way unless agreed by both parties in writing.

By my electronic signature below, I agree and certify that I have read and understood the contents of this consent form.

PLEASE READ THIS DOCUMENT CAREFULLY.

DO NOT SIGN THIS AGREEMENT BEFORE YOU HAVE READ IT COMPLETELY.

THE CLIENT HAS FULLY READ THIS AGREEMENT AND ANY SUPPLEMENT HERE TO, AND UNDERSTANDS AND AGREES TO ABIDE BY ALL OF THE TERMS HEREOF.

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