Elevate Performance & Recovery — Client Intake ELEVATE Performance & Recovery New Client Intake Form ✓ Form submitted successfully! We'll see you at your appointment. 1 Client Information Full Name * Date of Birth * Email * Phone * Address City / State / Zip Emergency Contact Name Emergency Contact Phone Relationship Occupation Referred By 2 Health History Primary Care Provider Overall Health Rating Excellent Good Fair Poor Current Medications Major Injuries, Surgeries, or Accidents (include approximate year) Allergies or Sensitivities Check All That Apply Anything Not Mentioned Above? 3 Informed Consent I understand that during my sessions at Elevate NH, I may receive manual therapy including hands-on soft tissue work and joint mobilizations (myofascial release, trigger point therapy, assisted stretching, Graston® IASTM, cupping therapy). I acknowledge there may be minor side effects such as temporary soreness, bruising, redness, or mild discomfort. I will communicate openly with my provider about any pain or sensitivity. I understand that Red Light Therapy uses low-level wavelengths to stimulate cellular function. I confirm I do not have photosensitivity or epilepsy triggered by light exposure, and I will wear appropriate protective eyewear as instructed. I understand that NormaTec Compression Therapy involves dynamic air compression sleeves. I confirm I do not have blood clots/clotting disorders, recent surgery, uncontrolled high blood pressure, cardiac/circulatory conditions, or pregnancy. I will notify my provider if any of these apply. I understand that corrective and functional movement exercises may be prescribed (mobility drills, postural/gait retraining, balance drills, core stabilization). I recognize exercise carries inherent risks and will inform my practitioner of any discomfort, dizziness, or pain. I acknowledge the Assumption of Risk & Hold Harmless Clause. I voluntarily participate and assume full responsibility for any risk of injury. I release, waive, discharge, and hold harmless Elevate Performance & Recovery LLC DBA Elevate NH, its owners, employees, contractors, and affiliates from any and all liability, claims, or demands for injuries, damages, or losses incurred in connection with services received. Consent to Treat: I consent to the above services being rendered by certified professionals at Elevate NH. I have had the opportunity to ask questions. I understand that I may withdraw consent and stop participation at any time. 4 Signature Full Name (typed signature) * Date * Parent/Guardian Name (if client is under 18) Parent/Guardian Date Submit Intake Form Your information is kept private and used only to provide you with safe, personalized care at Elevate NH.
