Myokinesis Therapy Intake Form

Myokinesis Therapy Intake Form

Complete Intake Form prior to scheduling appointment
Full name*

First NameLast Name
Address*

Street Address

Post Office Box

CityState

Postal / Zip CodeCountry
Cell Phone Number*

Area CodePhone Number
Home Phone Number*

Area CodePhone Number
E-mail*
Emergency Contact*

First NameLast Name
Emergency Contact Phone number*

Area CodePhone Number
Myokinesis Therapy Intake

Complete Intake Information, Attest and Authorize Treatment.
Birth Date*

MonthDayYear
Gender Male or Female*
Height *
Body Weight*
Were you referred by a Medical Professional or a client? Do you have an acute injury? Do you need emergency care? How did you hear about us? Please be specific.*
Describe your activities / hobbies and type of employment. Please be specific. Your lifestyle and type of employment play an important role in determining the most beneficial program for you.*
Has your Medical Doctor recommended against receiving Myokinesis Therapy, Personal Fitness Training or Massage Therapy? Do you suffer from any conditions that may prevent you from safely receiving Myokinesis Therapy, Personal Fitness Training or Massage Therapy.*
Are you in any pain or discomfort?*
If you are in pain or discomfort, have you seen a Medical Specialist?*
Please describe in detail, any pain, discomfort or concerns you may have. When did you first notice your pain/ discomfort or concerns? How often are you in discomfort?*
Have you had a Medical Physical in the past 12 months?*
Have you had Myokinesis Therapy, Personal Fitness Training, Corrective Exercise Training or Massage Therapy the past?*
What type of Therapy or Fitness Programs interest you?*
What are your goals?*
Do you suffer from Bone Disease or Joint Disease, including Arthritis? *
Do you have Joint Replacements, Corrective or Medical Implants*
Do you have Heart Conditions, High or Low Blood Pressure or Diabetes?*
Do you have any Vascular issues?*
Do you have any Medical Conditions, Allergies, or Musculoskeletal Pain?*
Are you currently taking Prescription Drugs or over the counter drugs?*
Do you have recent injuries, surgeries, open wounds or skin disorders.*
Do you have injuries or conditions that require special considerations?*
Do you suffer from any conditions that may cause hypersensitivity or a lack of sensitivity to heat or cold?*
Do you require any special care or bolstering for Fitness Training and / or Myokinesis/ Massage Therapy Sessions?*
Attest to Myokinesis Therapy Intake Information submitted and please *

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Balanced Body Studio Policy Agreement / Please Initial Agreement.
Myokinesis Therapy Policies
Myokinesis Therapy Treatment Protocol:
Myokinesis Therapy Treatment Protocol : Please complete the intake form with detailed description of your concerns. A MD clearance is generally recommended, however if you prefer, a Nurse Practitioner can evaluate Intake Information and forward treatment and Program recommendations. When your intake information is evaluated, our specialist will schedule an appointment. When you arrive for your appointment, our Myokinesis Therapist will complete a physical assessment, discuss appropriate treatment and continue with your scheduling a treatment. I understand the Policies set forth and authorize treatment and understand risks involved. We implement strict Safety Protocol and require all patients to follow those safety guidelines. Detail of our Safety Guidelines are noted on the "Safety Protocol Page" of our website.*
*Please note any concerns or questions regarding Myokinesis Therapy and / or Corrective Movement Treatments. If you have no concerns, please note NONE.
I agree to Myokinesis Therapy Treatment Protocol, Safety Protocols and Authorize Treatment. *

Clear
Balanced Body Studio Policy Agreement / Please Initial Agreement.
Medical Consent, Safety Protocol, and Acknowledgement Waiver:
Myokinesis Therapy takes all precautions in ensuring the safety and well-being of the client during Myokinesis/Massage Therapy Treatments and/or Fitness and Wellness Sessions in accordance with NYS Protocol and National Exercise and Sports Trainers Association. We recommend you receive Medical Clearance for your safety.

Medical Consent:

The client states they are fit for an Exercise Program/ Myokinesis/Massage Therapy Treatments and has received Medical Clearance for Fitness Training and/or Myokinesis/Massage Therapy Sessions and /or understands the risk of injury involved with increasing physical activity and/or receiving treatments without the consent of a physician and has decided to go forward with a Fitness Program and or Massage Therapy Program. The client further understands and consents assessments, program design, and/ or treatments by the Therapist/ Trainer. The Therapist/ Trainer recommends Medical Clearance by a Physician before starting Therapy and/or Fitness Sessions.

Acknowledgment Waiver :

The client is hereby requesting a Consultation and/or Services with Myokinesis Therapy, Pilates Fitness and Wellness, Balanced Body Fitness and Wellness LLC, Balanced Body Massages, and/or Daniel Thomas for the sole purpose of potentially retaining a Therapist or Personal Fitness Trainer and for no other reason. I acknowledge that I am not an agent or employee of any local, state, or federal government authority; or if I am employed as an agent or employer of any local, state, or federal government authority that I am seeking this consultation in my individual capacity and not the capacity as government agent or employee. If consultation is on behalf of a business entity and not an individual I further represent that I am either a principle, managing agent, partner or if a partner, or if an agent, that I am authorized to execute authorization and wavier on behalf of my principle.

I acknowledge that permission for me to enter the premises or any premises related to the ownership or business of Balanced Body Fitness and Wellness LLC, and/or to receive consultation and/ or services is based on the above acknowledgment, and any misrepresentation made herein in order to receive the consultation and/or services will be deemed entrapment and Trespassing with Malicious Intent, intentional infliction of emotional distress and all other applicable damages.

I waive any and all defenses I may have against me for entrapment, Trespassing with Malicious intent, Trespassing, Trespassing to Chattel, harassment, fraud in the inducement, intentional infliction of emotional distress, and any other damages incurred by Balanced Body Fitness and Wellness LLC and/or Daniel Thomas as a result of misrepresentation stated above for receiving consultation and/or services rendered to me.

I am aware that signing this document under false pretenses is a crime punishable under the laws of New York State.

I have read this document, understand its contents, and sign this waiver of my own will.

Safety Protocol and Waiver:

I read and understood Myokinesis Therapy, COVID-19 Safety Protocol, and Policies as noted in detail on our COVID-19 Safety Protocol Web Page.

Your safety is our priority and we strongly recommend medical clearance from a Medical Doctor before using our services. If you feel medical clearance is not necessary and you decide to go forward with our services, you are required to follow our strict safety protocols. You also understand and acknowledge that though our protocols are designed to minimize risk of injury.
Medical Consent, Safety Protocol and Acknowledgement Waiver Agreement*

Clear
Balanced Body Studio Policy Agreement / Please Initial Agreement.
Cancelation Policy:
At Myokinesis Therapy all appointments are binding. All sessions are prepaid. Rescheduling requests must be received at least 24h before your session in order to avoid being charged. Clients who do not request a rescheduling appointment within 24h notice will be charged 100% of the regular price of your session.
No Refund / Cancelation Policy Agreement*

Clear
Balanced Body Studio Policy Agreement / Please Initial Agreement.
NYS PICTURE ID / DRIVERS LICENSE (required to submit with Intake Form)*

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DOWN LOAD NYS PICTURE ID/DRIVERS LICENSE or Send copy of NYS PICTURE ID/ DRIVERS LICENSE via Text to 631.318.4696 Cancelof
Approved Date*

MonthDayYear
Should be Empty:

Myokinesis Therapy Intake Form

Myokinesis Therapy Intake

Myokinesis Therapy Policies

Myokinesis Therapy Treatment Protocol:

Medical Consent, Safety Protocol, and Acknowledgement Waiver:

Cancelation Policy: