Far Infrared Intake Survey

First Name *

Last Name *

Which are you?

New Client

Existing Client ( In the last 6 months )

*** I am 18 years or older. *

Yes

No

Are you submitting this intake form for your legal minor? Please list your full name, relationship to the minor and your cell phone number. By submitting this form, you give Dana Tescher consent to provide your minor child/person under my guardianship with therapeutic massage services as deemed appropriate to treat presenting conditions/injuries.

DATE OF BIRTH

- DON'T USE THE ARROWS -

Click on the MONTH & YEAR for drop down options

*

Referred by:

Address *

City *

State *

Postal code *

Email *

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Phone # *

Physician's Name *

Physician's Phone *

How would you rate your general health? *

Excellent

Good

Fair

Poor

Have you had a Far Infrared Sauna session before? *

Yes

No

If yes, when was your last treatment?

Reason for initial visit *

List any major accidents or surgeries (including dates)

List current medications & the condition they are treating:

Please tell us about any allergies or hypersensitivities:

- Assumed Risk -

I am aware of the benefits and risks and give my consent for a far infrared sauna session. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments.

I acknowledge that far infrared sauna sessions are not a substitute for medical care, medical examination or diagnosis.

I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

I understand that my personal health information will be collected and stored on a secure site..

I understand that all information that I provide will be kept confidential unless required by law.

I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment with my consent.

Treatments may be covered by extended health care plans such as HSA or FSA. I understand that it is my responsibility to confirm the exact details of my coverage.

24 hours notice is required to cancel or reschedule an appointment. I understand life happens and but please try your best. Cancellations made within 48 hours will receive a 50% refund. Cancellations made within 24 hours will not receive a refund. Failure to cancel appointments at least 24 hours in advance or failure to show up for your appointment will result in a charge of 100% of the scheduled appointment fee which will be processed on the credit card retained on file to reserve appointment or will be charged before another appointment can be scheduled.

*

I have read, understand and agree with the cancellation policy.

If you are a CASH ONLY client, please put C in each location.

Name As It Appears On Card *

Billing Address on Card *

16 Digit Card Number *

Expiration Date *

Security Code *

REMINDER: 24 hours notice is required to cancel or reschedule an appointment. I understand life happens and but please try your best. Cancellations made within 48 hours will receive a 50% refund. Cancellations made within 24 hours will not receive a refund. Failure to cancel appointments at least 24 hours in advance or failure to show up for your appointment will result in a charge of 100% of the scheduled appointment fee which will be processed on the credit card retained on file to reserve appointment or will be charged before another appointment can be scheduled. *

I have read, understand and agree with the cancellation policy.

Have you had any updates to your health since your last treatment? Please describe below. If NONE please type NA *

Phone *

Consent For Treatment *

By submitting this form, I am consenting to a wellness appointment with Dana.

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