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Intake Form

Intake Form

Your success is our #1 priority. Help us to help you achieve that success by filling out this questionnaire as completely as possible.
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    • Male
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    Please include all medications and supplements you are taking
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  • 23
    When you are Fascia Blasting and restoring a fascial adhesion, it’s like pulling two pieces of duct tape apart.There’s going to be some inherit bruising that comes with that type of restoration. It’s a sign that you’ve successfully separated the sticky layers of tissue. Blood rushes to the scene so that healing can begin in that area.When someone is fascially restricted it’s like having a kink in a garden hose. When you open the fascia, all of the sudden you have blood flowing to that area again. These types of bruises are not painful but they can be immediately visible. They can also be accompanied by a tingling feeling as blood rushes through the tissue. When you are Fascia Blasting fat cells where fat has adhered to the layers of fascia or muscle, you will get micro fissures in the capillaries as it’s pulled apart. This leaves space for the oxygen-rich blood cells to move in and gobble up and breakdown the fat cells.Are you okay with bruises? Is your significant other? During summer months when extra skin is exposed, you may not want to be as aggressive with treatment. Or maybe you’re a fast tracker willing to endure for the prize ahead.Again, it’s all about how quickly you want to see results! Being a bruiser or not being a bruiser is your choice. It boils down to your personal level of pressure and how bound your fascia is. Bound fascia will bruise more easily but it still depends on how much pressure is applied. But just because you bruised in an area the first time, doesn’t mean you will the second time. You should quickly notice a difference the next time
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  • 24

    Go into a hot room, sauna, and bath, whatever. The hotter the better.

    This is why we offer Fascia Blasting in our sauna

    Hydrate: Fascia actually has liquid running through it and if you are dehydrated (most people don’t know it when they are) your fascia is going to be sluggish instead of clean. Make sure you hydrate first with water and make sure you are getting electrolytes!

    The FasciaBlaster™ is a tool used to release adhesions and restrictions in the Fascia, promote blood flow and increase range of motion. The increased circulation and breakup of myofascial adhesions, some discoloration in the skin may occur. It is temporary and part of the body’s normal healing process.

    FasciaBlaster™ is best used in a series of 1-3x’s per week for 6-8 weeks and follow up with in home use.

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    People who are

    • Pregnant
    • Have any Blood Clots
    • Taking any blood thinners

    If you start taking such medication please inform the therapist so your treatment plan can be adjusted. Fascia Blasting has provided me with information on the FasciaBlaster™ techniques. If I choose to experience this therapy in my treatment, I understand the effects and after-care recommendations. It has been explained to me there is the possibility of a temporary skin discoloration like bruising or tenderness appearing as tissue is released. I am aware that I may bruise and that it will dissipate within a few days. I understand that all treatments by the therapist at this facility are therapeutic in nature and that I may feel flu like feelings and possibly a little nausea when my body releases the toxins.

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    I agree to notify the therapist of any physical discomfort experienced during the session. I have stated all relevant physical conditions, and will inform the therapist of any changes in my health.
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    Signature below is my understanding of above information and consent to treat.
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