Fascial Release Intake
Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Describe your symptoms or areas of discomfort
Duration of symptoms (in weeks)
Have you had any previous treatments for these symptoms?
Yes
No
If yes, please provide details of previous treatments
Back
Next
Fascial Release Contraindication AcknowledgmentI understand that Fascial Release is a hands-on therapy intended to promote relaxation, improve mobility, reduce pain, and support healthy fascial movement throughout the body. I confirm that, to the best of my knowledge, I do not currently have any of the following conditions that may make treatment unsafe or require medical clearance: *Acute fracture or recent significant injury. *Open wounds, unhealed surgical incisions, or severe burns. *Active infection, fever, or contagious illnessDeep vein thrombosis (DVT) or suspected blood clot. *Active cancer in the area being treated, unless cleared by my physician. *Active bleeding disorder or uncontrolled bleeding. *Severe osteoporosis or other condition causing fragile bones. *Pregnancy (unless disclosed and treatment has been discussed). *Recent surgery, steroid injection, or other procedure requiring treatment modifications. *Uncontrolled medical conditions or any other health concern that may affect my ability to safely receive Fascial Release
I do NOT
I DO
Submit
Should be Empty: