LIFEDANCE
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LifeDance Manual Session Intake Form
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Name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
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Email
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What kind of manual work are you interested in?
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Physical Therapy Services
Integrative Manual Therapy
Craniosacral Therapy
Myofascial Release
Manual Restorative Release Yoga
Vagus Nerve Rebalancing
Other
Diagnosis / Region of involvement
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Please provide a brief, general medical history. Include surgeries in the last six months and any applicable precautions. Please include injuries, orthopedic, or other issues affecting your health/wellbeing
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Please specify medications or supplements you are taking
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Primary Care Physician
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Emergency Contact/Phone
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Additional information such as stress level, what kind of exercise or self-care you participate in, or other interventions you have worked with
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I hereby agree to the following liability waiver:
1. I am agreeing to physical therapy and/or manual therapy session(s) where I will participate in hands-on interventions and may participate in movement and wellness practices. I recognize and am aware of the risk of injury inherent therein.
2. I am participating in these services for wellness purposes, and that these services are adjunct to general medical intervention and assessment. I contend that it is my responsibility to consult with my physician regarding my participation if indicated. I represent that I have no medical condition that would prevent safe participation in these services.
3. In agreement for participation, I assume full responsibility of any risk, injury or damage, known or unknown, now or in the future, that may incur as a result of participation in LifeDance services, activities, or movements, and waive any claim I may have against LifeDance, Susan Thompson-Brown, MPT, DPT, RYT, or the facility of Scarborough Physical Therapy Associates, PA now and in the future.
4. I agree to inform Susan Thompson-Brown, MPT, DPT, RYT of any change in medical status that may affect my participation in these services.
I have read the above liability waiver, understand the conditions, and agree to terms specified. By submitting this form, I am voluntarily signing this agreement as a digital signature, which serves as complete and unconditional release of all liability.
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