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Health History
This information helps ensure services are safe and appropriate for you.
General Health
Check All That Apply
Please rate your overall health before continuing.
Informed Consent
Please read each section carefully and check to confirm your understanding.
1. Informed Consent for Manual Therapy & Therapeutic Tools
I understand that during my sessions at Elevate NH, I may receive manual therapy, including hands-on soft tissue work and joint mobilizations, which may include:
Myofascial release
Trigger point therapy
Assisted stretching
Graston® (IASTM) technique
Cupping therapy
2. Red Light Therapy & NormaTec Compression Therapy
I understand that red light therapy uses low-level wavelengths to stimulate cellular function, potentially aiding in recovery, inflammation reduction, and performance. I confirm that:
I do not have photosensitivity or epilepsy triggered by light exposure.
I will wear appropriate protective eyewear as instructed.
3. Movement Therapy and Corrective Exercise
I understand that corrective and functional movement-based exercises may be prescribed as part of my wellness and neuromuscular rehabilitation plan. These may include:
Mobility drills
Postural and gait retraining
Balance and coordination drills
Core activation and stabilization techniques
4. Assumption of Risk & Hold Harmless Clause
I acknowledge that I am voluntarily participating in services provided by Elevate NH and understand that there are inherent risks associated with physical activity, manual therapy, and the modalities listed above.
5. Consent to Treat
By completing this form, I consent to the above services being rendered by certified professionals at Elevate NH. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction. I understand that I may withdraw consent and stop participation at any time.
Please check all consent boxes before continuing.
Signature
Sign below to confirm your intake before moving to payment.
Client Signature *
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Your signature confirms agreement to all sections above.
Please provide your signature and printed name before continuing.
Session Payment
One last step — complete payment to confirm your appointment.
Session Fee: $975
This covers your scheduled session(s) at Elevate Performance & Recovery. Payment is made via Venmo. Tap the button below to open Venmo with the amount and recipient prefilled, or send manually using the handle below.
Manual payment instructions: Open the Venmo app or venmo.com, search for @Josh-Tamblyn, and send $975. Please include "Evan Hill" in the payment note so it can be matched to your intake.
Please confirm payment before submitting your intake.
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Intake Complete
Thank you, your intake form has been submitted successfully.
A copy has been sent to the email you provided.
Elevate Performance & Recovery — Berlin, NH We look forward to seeing you.