Client Intake Form

Please fill out the following form with as much detail as possible, in order to provide you with the best possible treatment tailored to your specific needs

Client Information

Personal History

ElectronsPlus/PEMF Absolute Contraindication List

24-Hour Cancellation Policy

Aftereffects Acknowledgement

Parental Consent for Minors

Full Name

Today's Date Please select or type a date

Date of birth Please select or type a date

Contact Phone

Emergency Contact Name

Emergency Contact Phone

Reason For Visit General wellnessDepressionSleep deprivationAnxietyPain reliefRelaxation

Are you in pain right now? If YES, please explain: NOYES

Please explain:

Chronic conditions? If YES, please explain: NOYES

Please explain:

Panic attacks? If YES, please explain: NOYES

Please explain:

Lacerations or bad cuts? If YES, please explain: NOYES

Please explain:

Can you please remember any/all injuries or accidents you've had in your life? (Old injuries can be negatively affecting you today) If YES, please explain: NOYES

Please explain:

Do you exercise? If YES, please explain how often and what is your regiment: NOYES

Please explain:

Do you take medications? If YES, please list: NOYES

Please list:

How is your blood pressure NormalHighLow Please list all scars you may have either from injury or surgeries. (This is important because scars from any type of trauma can cause myofascial restrictions which in turn can cause muscle and/or joint pain). Do you have any history or issues with blood clotting? If YES, please explain in detail: NOYES

Please explain:

Previous Therapy Experience Have you had massage therapy before? YESNO Have you ever experienced PEMF therapy? YESNO Have you had cupping therapy before? YESNO ElectronsPlus / PEMF Absolute Contraindication List Please mark YES or NO if you experience or have any of the following: 1. Pacemakers or implanted electronic devices: Includes cardiac pacemakers, cochlear implants, insulin pumps, or neurostimulators. PEMF may interfere with their function. YESNO 2. Pregnancy: The effects of PEMF on fetal development have not been adequately studied. YESNO 3. Active cancer: PEMF is generally contraindicated for active malignancies, as it may theoretically promote tumor growth (though this is debated and requires further study). YESNO 4. Seizure disorders: Particularly for high-intensity PEMF, as it might provoke seizures. YESNO 5. Active bleeding or hemorrhage: PEMF may enhance circulation, potentially worsening active bleeding. YESNO 6. Acute infections or fever: PEMF may exacerbate the inflammatory response during an active infection. YESNO 7. Thrombosis or deep vein thrombosis (DVT): PEMF can improve circulation, which might dislodge a clot and lead to embolism. YESNO

METHODS OF PAYMENT

Cash or Check

Apple Pay

Zelle

Please ensure your accounts are active and ready to use at the time of payment.

(Unfortunately, we are not accepting Debit or Credit Cards at this time.)

24-Hour Cancellation Policy I agree that, If I schedule an appointment in the future, I promise to pay for my session if I cancel without giving 24 hours of notice*. (*Medical emergencies are exempt).

Date Please select or type a date

Initials Please type your initials as a sign of acceptance

Please Read and Acknowledge the Possible Aftereffects of ElectronsPlus Treatments and Cupping Treatments ELECTRONSPLUS THERAPY ElectronsPlus treatments –aka PEMF therapy– is very powerful and will greatly improve blood circulation in the body. You may feel a deep sense of relaxation mixed with a burst of energy. Because of the therapeutic process you may experience detoxification symptoms like migraine headaches, muscle soreness, possible nausea and drowsiness. These symptoms are the body‘s way of pushing out toxins. This is a completely normal response. Please drink lots of water directly after your treatment. Electrolyte water is recommended. Do you agree to accept the ElectronsPlus treatment? YESNO PEMF / ElectronsPlus Pulsed Electromagnetic Field Therapy Treatment Acknowledgement I understand that PEMF therapy uses electromagnetic fields to promote healing and that: - Sessions may typically last 15-30 minutes. - Effects may vary from person to person. - Some people may experience temporary fatigue or mild discomfort. - Multiple sessions may be needed for optimal results. Contraindications: I understand that PEMF Therapy is NOT recommended for: - Individuals with electrical implants (pacemakers, etc.). - Pregnant women. - Active bleeding or hemorrhage. - Active cancer treatment (unless approved by physician). I confirm that none of these contraindications apply to me, or I have received medical clearance from my healthcare provider. I agree to inform the therapist of any changes in my medical condition.

Please type your initials as a sign of acceptance and acknowledgement for ElectronsPlus Therapy

DEEP MYOFASCIAL CUPPING Please read this thoroughly before your first session This treatment is extremely powerful and highly effective. LONG TERM PAIN relief is usually noticed the most between session 5/7. Sooner in some cases. Toxins trapped in your body will be released into your blood stream causing headaches, lethargic feelings, drowsiness, possibly nausea. THIS IS THE NATURAL HEALING PROCESS. Drink plenty of water. Only use heat packs if needed on sore areas, AVOID ICE. These after effects become less noticeable after your first session. Cupping marks are almost always inevitable. They clear up usually in 5-14 days. Do you agree to accept the Deep Myofascial Cupping treatment? YESNO

Please type your initials as a sign of acceptance and acknowledgement for Deep Myofascial Cupping

PARENTAL CONSENT FOR MINORS Are you an adult providing a parental consent for a minor? NOYES

My name is

, and I am the parent/legal guardian of

I give permission to Michael Santana of True Wellness Therapies to perform therapeutic modalities for the benefit of my minor child. The therapies I approve include, but are not limited to: 1) Cupping Therapy, 2) Massage Therapy, 3) PEMF Therapy, and/or 4) Fascial Scraping Techniques.

Date Please select or type a date

Please type your initials as a sign of acceptance for the Parental Consent

By submitting this form, I authorize the collection, processing, and storage of my personal data as provided herein. I understand that this information will be used to process my application, provide me with a tailored treatment, and send marketing communications, by True Wellness Therapies.