Recovery Services Intake Form

1
Scheduling: Next Steps

Upon completing this form you will be redirected to one of the following:

Initial Assessment Via:

- 15m Consult call

- Email

Booking your First Session:

- 35m Recovery Session

- 45m Recovery Session
2
Name* This field is required.
First Name
Last Name
3
Email* This field is required.
example@example.com
4
Mobile Number* This field is required.
Area Code
Phone Number
5
Can you receive text messages at the number you included?* This field is required.
YESNO
6
Date of Birth* This field is required.
Date
Month
Day
Year
7
Height: * This field is required.
8
Weight: * This field is required.
9
Emergency Contact Full Name, Relation and Phone Number* This field is required.
Huge
Large
Normal
Small
Ok
Ok
10
How did you hear about us?* This field is required.If referred to us by someone, what is their name?
11
Check any that apply* This field is required.
Cardiovascular conditions (e.g., heart disease, blood pressure, arrhythmias)
History of fainting, dizziness, or heat/cold intolerance
Currently pregnant or trying to become pregnant
Diabetes (Type 1 or Type 2) or any Endocrine Conditions (Thyroid or Adrenal Disorders)
Current illness (e.g., fever, infection, flu‑like symptoms)
Medications that affect heart rate, blood pressure, or temperature regulation, including chemotherapy
Open wounds, skin conditions, or recent surgeries
Regularly experience low blood pressure or orthostatic hypotension
Conditions affecting ability to sweat or regulate temperature (e.g., multiple sclerosis, Parkinson’s)
History of seizures, loss of consciousness, or heat stroke
Vertigo
Hormonal imbalance
None of the above
Other
12
Have you ever been diagnosed with or treated for anxiety, depression, or other mental health concerns?* This field is required.
YESNO
13
If answered "yes," to the question above, tell us more.
Huge
Large
Normal
Small
Ok
Ok
14
Are you allergic to Chlorine, Muriatic acid, or any other things we should be aware of?* This field is required.
YESNO
15
If answered "yes," to the question above, tell us more.
Huge
Large
Normal
Small
Ok
Ok
16
Goals (select all that apply)* This field is required.
Metabolic health / body‑comp support (insulin sensitivity, brown fat, “fat‑burn assist”)
Alertness, focus, mood lift / resilience
Stress relief / relaxation
Improved sleep quality
Soreness relief / general recovery
Athletic performance
Pain management
Impact on mental health/ mental toughness
Longevity
Nothing specific / curious to see impact
Other
17
More specifically- please select areas you want help with:Select all that apply
Sleep issues (falling/staying asleep)
Energy slumps (e.g., 2pm crash)
High stress levels
Hormonal imbalance
Metabolism
Other
18
Have you ever done contrast therapy, cold plunges, or sauna sessions before? If so tell us about your usage. Describe your experience. If you have cold plunged, how cold was the water. If you have done a sauna session was it Swedish or infrared?
Huge
Large
Normal
Small
Ok
Ok
19
Anything else we should know about you?
Huge
Large
Normal
Small
Ok
Ok
20
Any goals or events that are happening in your future - in sport or life. Please list below
Huge
Large
Normal
Small
Ok
Ok
21
TD Athletes Edge Waiver and Consent * This field is required.By signing this document or continuing with treatment, I hereby consent to receive therapeutic services provided by TD Athletes Edge, including but not limited to Class IV Laser Therapy, RPW2 Shockwave Therapy, Physical Therapy, Massage Therapy, and Movement Sessions. I acknowledge that these services are administered by licensed or certified professionals, and I understand the nature, purpose, potential risks, and expected benefits of each modality. I understand that Laser and RPW2 Shockwave therapies are FDA-cleared, non-invasive interventions designed for the temporary relief of musculoskeletal pain, spasm, and circulation improvement, and that physical therapy interventions may include manual therapy, exercise, and the application of physical agents. I further understand that therapeutic results vary by individual, and no guarantees or warranties have been made as to the outcome or duration of benefits. I acknowledge that certain procedures may cause temporary discomfort, soreness, or aggravation of pre-existing conditions. I understand that protective eyewear is required during laser treatments, and I will comply with all safety protocols and pre-treatment instructions, including the removal of reflective objects. I affirm that I have disclosed all known medical conditions and physical limitations, and I agree to notify TD Athletes Edge in writing of any changes to my health status prior to subsequent sessions. I understand that massage therapy services rendered are not intended to diagnose or treat medical conditions, and I am responsible for seeking care from a licensed physician for any underlying health concerns. In consideration of the services provided, I, on behalf of myself, my heirs, and assigns, do hereby release and hold harmless TD Athletes Edge, its employees, officers, and agents from any and all claims, liabilities, or causes of action arising out of or related to the performance of said services. We are located at 63 1/2 Jefferson Ave in Salem MA. There is parking to the right of the building. You will enter the door marked TD Athletes Edge. Once you enter the building you will have a seat or wait in the waiting area right inside the door. I will meet you at the time of your appointment. Please wear or bring workout clothes that allow you to move freely and allow me to get directly to the areas we will be working on (ie. shorts for hips & knees or tank tops/sports bras for shoulders). We do have a 24 hour cancellation policy. If you have to cancel within 24 hours of your appointment time, you will be charged for the appointment. Please text us if you need to cancel and it is within the 24 hour window (at which point you cannot cancel on the square app) 978-712-0260
Powered by Jotform SignClear
22
What would you like to do next?* This field is required.Select One
Book my Free Demo (Select on next page, Members Only Recovery Demo)
Book a Consult Call
Book my first session
Book a Consult Email
Should be Empty: