Fascial Stretch Therapy

Intake Form

Langley Fascial Stretch Therapy

Let’s get Started

Please fill out the form below. Our therapist may reach out with additional questions if needed.

Get ready to feel better.

Personal Details

Full Name

Date of Birth

Email Address

Phone Number

Street

City

Postal

Emergency Contact Info

Emergency Contact Full Name

Emergency Contact Relationship

Emergency Contact Number

Medical History

Medical Conditions Medical Conditions Do you have any current medical conditions or injuries? (e.g., diabetes, heart disease, recent surgeries, etc.) ? Yes No

Medical Conditions Explained

Current Medications? Current Medications? Are you currently taking any medications? Yes No

Medications Used

Alergies? Alergies? Do you have any allergies? Yes No

Allergies specified

Other Treatments? Other Treatments? Have you had any previous treatments or therapies for your condition? Yes No

Treatments Specified

Lifestyle and Activity Level:

Physical Activity Frequency Physical Activity Frequency How often do you engage in physical activity or exercise? Daily A Few Times/Week Weekly Occasional Rarely

Types of Activity What types of physical activities or exercises do you typically perform?

Pain During Exercise Pain During Exercise Do you experience any pain or discomfort during physical activities? Yes No

Treatments Specified

Fascial Stretch Therapy Specific Questions:

Previous FST Previous FST Have you received fascial stretch therapy before? Yes No

FST Goals What are your primary goals for seeking fascial stretch therapy? (e.g., pain relief, increased flexibility, stress reduction, etc.)

Focus Areas Are there any specific areas of your body that you would like to focus on during the sessions?

Acknowledgement and Agreement:

I acknowledge and agree to the following terms and conditions:

Fascial stretch therapy is a clothed activity.
It is recommended to wear loose-fitting clothes that allow full range of motion.
Sessions will primarily take place in a private setting in the clubhouse, but may also occur in the gym or outside if appropriate. Your comfort is our utmost concern but FST is not necessarily a "private" activity.

Costs

I acknowledge and agree to the following terms and conditions regarding costs:

1 hour FST sessions - $115.
30 min FST sessions - $65.
For ICBC patients, $92 will be covered by ICBC, but the remaining $23 + GST must be paid on the day of the session.
For Vaughan's Fitness clients with weekly recurring master time spots, FST can be added to their monthly bill; for all other clients, FST must be paid on the day of the session.
GST is added to all costs.

Liability Waiver:

I, the undersigned, understand that fascial stretch therapy involves physical movement and stretching which may carry some risk of injury. I acknowledge that I am voluntarily participating in these activities and assume all risk of injury or harm associated with participation. In consideration of my participation in fascial stretch therapy, I hereby release, waive, discharge, and covenant not to sue Vaughan's Fitness Inc., its owners, officers, employees, or agents from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me, whether caused by the negligence of the releasees or otherwise, while participating in such activity, or while in, on, or upon the premises where the activity is being conducted.

Privacy Policy:

I understand that my personal and medical information will be kept confidential and will only be used for the purposes of providing fascial stretch therapy services. Vaughan's Fitness Inc. is committed to protecting my privacy and will not share my information with third parties without my explicit consent unless required by law. I acknowledge that Vaughan's Fitness Inc. has implemented appropriate physical, technical, and administrative measures to safeguard my personal information. I consent to the collection, use, and disclosure of my personal information as described in this policy.

Consent to Treatment:

Agree Agree I acknowledge that I have read, understood, and agree to all the terms and conditions outlined in this intake form, including the Acknowledgement and Agreement, Liability Waiver, Privacy Policy, and Consent to Treatment sections. Yes No

I hereby consent to receive fascial stretch therapy from Vaughan's Fitness Inc. I understand that I may withdraw my consent and discontinue participation at any time.

Consent Signature Sign Here: (***Click Save In the Box After Signing) Save Clear

Date Signed