BIOMOTIVES Sports Recovery Health Intake & Waiver

BIOMOTIVES Health Intake & Waiver

“Shift gears to feel brand new”
Client's Name*

First NameLast Name
Parent’s Name

First NameLast Name
Birth Date*

MonthDayYear
Date
Phone Number*
Email Address:*
example@example.com
Sport/Team/Position*
Example: Basketball/Ravens/Guard or N/A
Do you have any of the following?

AccidentNeck PainWhiplashHeadachesShoulder PainUpper Back PainMid back painLower back painJoint AcheLimited Range of motion.Broken BonesSprainsSeizuresAbdominal PainNervous TensionArthritis or goutAllergies to scentsWear contactsScoliosisSurgeryFibromyalgiaCarpal TunnelMastectomyDiabetesVaricose VeinsHigh Blood PressureStrokeHeart AttackCancerHIVRotator Cuff IssuesOsgood-SchlattersConcussionHip Flexor StrainACL Tear or StrainGroin PullShin SplitsSciaticaHamstring StrainTennis or Golf ElbowShoulder InjuryPatellofemoral SyndromeTendinitisBursitisImpingementLittle League ElbowRunner’s KneeMeniscal TearAnkle SprainAchilles TendinitisFracturesOther
Where do you feel pain/discomfort?
Are you taking any medications? If so, describe:
Have you had any surgeries? If so, where and when:
Are you pregnant?

No2nd Trimester3rd Trimester
Have you ever received massage or sports recovery therapy?*

YesNo
Type of massage received?

Deep TissueSwedishNew to massageOther
Rate your water consumption level:

1

2

3

4

5

1 is Low, 5 is High
Reason for treatment*

Relieve StressPromote relaxationSleep betterReduce muscle tension/sorenessRelieve tension headacheEnhance exercise performanceManage Lower back painHelp chronic neck painRelieve postoperative painRelieve osteoarthritis painEnhance range of motionIncrease flexibilityOther
Do you have any of the following:*

SunburnSevere painInflammationHeadachesOpen cuts, bruises, burnsIrritated Skin RashPoisonCold/FluCOVID-19 symptoms: Fever, fatigue, dry cough, difficulty breathing, GI issuesInjuriesNoneOther
By signing this waiver/liability form, I acknowledge and confirm the following:*

I give my permission to receive sports recovery servicesI acknowledge that sports recovery & massage therapy is not a substitute for medical care, medical examination and diagnosis.I understand that the service provider does not diagnose illnesses or injuries, or prescribe medications.I have stated all medical conditions that I am aware of and will inform my practitioner of any changes inmy health status. I have clearance from my physician to receive massageI understand the risks associated with sports recovery therapy include, but are not limited to; superficial bruises or redness, short-term muscle soreness, exacerbation to undiscovered injury.I therefore release the service provider from all liability concerning these injuries that may occur during the massage session.I understand the importance of informing the service provider of all medical conditions and medicationsI am taking, and to let the service provider know about any changes to these. I understand that theremay be additional risks based on my physical condition.I understand that it is my responsibility to inform the service provider of any discomfort I may feel during the session so he/she may adjust accordingly.I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my personalinformation may be shared by the various care providers involved in my care and treatment.I understand that I or the service provider may terminate the session at any point in time.I have been given a chance to ask questions about the session and my questions have been answered.
Treatment Modalities:*

I give my permission to receive treatment services that includes treatment modalities. including: compression boot therapy, assisted stretching, and sports recovery treatments.(For sports recovery treatment ONLY) I hereby acknowledge that I have voluntarily chosen to receive decompression therapy from BIOMOTIVES. I understand and agree to the following: Decompression cupping is a therapeutic technique that involves the use of suction cups on the skin to promote relaxation and potential relief from muscle tension and discomfort. I understand that decompression cupping is not a substitute for medical treatment or diagnosis and that it is solely a wellness and relaxation modality. Risk and limitations: I am aware that decompression therapy marks and bruising on the treated areas, which is a normal and expected response.I acknowledge that any treatment modality listed above may not be suitable or advised for any individuals with certain medical conditions, such as pregnancy, skin infections, or blood clotting disorders.I have disclosed any relevant medical conditions or concerns to the therapist prior to any treatments using treatment modalities.
Release of Treatment Liability:*

I release BIOMOTIVES, its therapists, employees, and representatives from any liability for any injury, discomfort, or adverse reaction that may occur as a result of: decompression cupping therapy, assisted stretching, compression therapy, cryotherapy, hydrotherapy, hot stones, thai massage technique, myofascial release, and infrared light therapy.I understand that any treatment modality listed above is performed by a trained professional, but will communicate any discomfort or concerns during the session and follow any post-treatment instructions provided.I acknowledge that any treatment modality listed above may not be suitable or advised for any individuals with certain medical conditions, such as pregnancy, skin infections, or blood clotting disorders.I acknowledge that I have read and understood the contents of treatment modality waiver and freely assume all risks associated with the therapy.
Policy Notification*

Cancellation Policy: We respectfully ask that you provide us with a 24-hour notice of any schedule changes or cancellationrequest. Please understand that when you cancel or miss your appointment without providing a 24-hour notice we are often unable to fill that appointment time. This is an inconvenience to your therapist and also means our other clients miss the chance to receive services they need. For this reason, you will have to reschedule for another day. You will also forfeit session credit if you are a “no call, no show”. We understand that emergencies can arise and illnesses do occur at inopportune times. If you have a fever, a known infection, or have experienced vomiting or diarrhea within 24 hours prior to your appointment time, we request you cancel your session. Inclement weather may also result in need for late cancellations. We will do our best to give advanced notice if we are closing or need to cancel due to bad weather or illness and we ask that you do the same. Please do not risk your own safety trying to make your appointment. Late cancellation due to emergency, illness, or inclement weather will generally not result in any missed session credit, but this is determined on a case-by-case basis.Late Arrival Policy: We request that you arrive 5-10 minutes prior to your appointment time to allow time to answer any intake questions your therapist may have. We understand that issues canarise that may cause you to be late for your appointment. However, we ask that you call or text to inform us if this ever occurs so we can do our best to accommodate you. Appointment times are reserved for each client, so often times we cannot exceed that reserved time without making the next client late. For this reason, arriving after your appointment time may result in loss of time from your treatment so that your session ends at the scheduled time. Full service fees will be charged even when sessions are shortened due to late arrival. In return we will do our best to be on time, and if we are unable to do so we will add time to your session to make up for our late arrival or adjust the session credit.Inappropriate Behavior Policy: Sports Recovery is for optimizing performance and well-being purposes only. There is absolutely no sexual component to treatment whatsoever.
This Agreement is entered into by and between Simona Simmons (herein after known as “recovery therapist/practitioner”) and the undersigned client (hereinafter known as “Client”) for the purposes of setting a provision of sports recovery services by recovery therapist/practitioner to Client, and Client’s use of any premises, facilities or equipment are contingent upon this Agreement.

TREATMENTS PROTOCOL:

Treatments may include; Compression Boot Therapy, PNF & assisted-stretching, percussion therapy, k-taping, functional movement training, decompression cup therapy, myofascial release, kinesio-taping, and more.

Baseline and follow-up assessments are implemented to track treatment progression. Each client will have access to progression sheet upon request.

MEDIA RELEASE:

I grant BIOMOTIVES permission to use photographs, videos, or other media recordings taken during non-disclosed participation in treatment sessions by BIOMOTIVES. This includes promotional materials, websites, social media, and marketing purposes. I understand that I will not receive any compensation for the use of any image or likeness. I release BIOMOTIVES from any liability arising from the use or publication of the media recordings.

ACKNOWLEDGEMENT:
By signing this release, I hereby waive and release Biomotives, LLC, No Limit Fitness KC, and Dynasty from any and all liability, past, present, and future relating to recovery therapy & bodywork treatment sessions.
Client's Signature (Adult)*

Clear
Parent/Guardian Signature (To any minor that is UNDER the AGE OF 18, I hereby waive and release my minor to receive sports recovery treatment)

Clear
Date Signed*

MonthDayYear
Date
Should be Empty:

BIOMOTIVES Health Intake & Waiver