Elevate Performance & Recovery · Berlin, NH New Client Intake You're all set. Your intake form has been submitted.We'll see you at your appointment. Questions? Text us at (603) 803-3238. 01 Client Information Full Name * Date of Birth * Email * Phone Street Address City / State / Zip Emergency Contact EC Phone Relationship Occupation Referred By 02 Health History Primary Care Provider Overall Health Excellent Good Fair Poor Current Medications Major Injuries, Surgeries, or Accidents (include approx. year) Allergies or Sensitivities Check All Conditions That Apply Areas of Swelling Autoimmune Disorder Back / Neck Problems Bleeding Disorders Bruise Easily Bursitis Cancer Decreased Sensation Diabetes I Diabetes II Fibromyalgia Headaches Heart Condition Hypotension Hypertension Kidney Disease Multiple Sclerosis Neurological Condition Neuropathy Osteoarthritis Osteoporosis Sciatica Seizures Stroke Tendonitis TMJ Varicose Veins Vertigo Anything Else to Note? 03 Informed Consent Manual Therapy — Myofascial release, trigger point therapy, assisted stretching, Graston® IASTM, and cupping. Minor side effects (soreness, bruising, redness) are possible. I will communicate any pain or sensitivity to my provider. Red Light Therapy — Low-level wavelengths to support recovery. I confirm I have no photosensitivity or light-triggered epilepsy, and will wear protective eyewear. NormaTec Compression — Dynamic air compression sleeves. I will notify my provider of any blood clots, recent surgery, uncontrolled hypertension, cardiac conditions, or pregnancy. Corrective Movement — Mobility drills, postural retraining, balance and core work. I will report any discomfort, dizziness, or pain to my practitioner. Assumption of Risk & Hold Harmless — I voluntarily participate and release Elevate Performance & Recovery LLC DBA Elevate NH, its owners, employees, and affiliates from all liability for injury or loss from services received. Consent to Treat — I consent to services from certified professionals at Elevate NH and understand I may withdraw at any time. Please check all consent boxes to continue. 04 Signature By typing your full name below you are providing a digital signature agreeing to all statements above. Full Name — Digital Signature * Date * Parent / Guardian Name (if under 18) Guardian Date Submit Intake Form Something went wrong. Please try again or email josh@elevatenh.com directly. Your form will be sent securely to Elevate NH. Questions? Text (603) 803-3238
