Client Confidential Intake Form

    Date of Birth

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    Medical History (Please click all that apply)

    Compression Therapy Health Screening

    Compression therapy is a non-invasive modality proven to assist with increasing circulation and range of motion, relaxation & recovery. Reduce pain and soreness, boost pressure to pain threshold and clear muscle cell metabolites from the limbs after physical activity. This modality pairs compression with a sophisticated massage pattern, employing three key forms of biomimicry, including pulsing, gradients, and distal release

    – The pulsing action uses dynamic compression, effectively mimicking the muscle pump of the legs and arms, to greatly enhance the movement of fluid and metabolites out of the limbs.

    – Hold pressures are used, similar to the one-way valves of veins and lymphatic vessels, to prevent fluid backflow, and enhance the natural circulatory flow.

    – The distal release feature releases hold pressures once they are no longer needed, ensuring that each portion of the limb gains maximal rest time without a significant pause between compression cycles.

    Once you are set up on the devices, you will first experience a pre-inflate cycle, during which the attachments fill with air to calibrate and mould to their exact body shape. The session will then begin by compressing your feet. Similar to the kneading and stroking done during a massage, each segment of the attachment will first compress in a pulsing manner and then release. This will repeat for each segment of the attachment as the compression pattern works its way up the limb. This stimulates blood flow, massages the muscles, and works in harmony with the body’s circulatory system to mobilize fluid out of the extremities and back up towards the heart.

    I understand the above and consent to treatment.

    Do you currently have any open wounds, contusions or abrasions?

    Are you recovering from a recent surgery and have sutures or stiches?

    Are you suffering from severe atherosclerosis, acute deep vein thrombosis, or other ischemic vascular diseases?

    Are you suffering of congestive cardiac failure?

    Do you have an existing pulmonary embolism or pulmonary edema?

    Do you have a local skin condition such as gangrene, untreated or infected wounds, recent skin graft or dermatitis?

    Have you been diagnosed with lumphangiosarcoma?

    PLEASE COMPLETE THE BELOW IF THE PATIENT IS UNDER THE AGE OF 18.

    By clicking “I Agree”, I acknowledge that (A) I have read, understand, and fully agree to the foregoing CONSENT, (B) the proposed usage of the NormaTec equipment has been satisfactorily explained to me and I have all of the information I desire and (C), I hereby give my authorization and consent. This CONSENT shall stand as long as I use the NormaTec equipment at Opulence Mobile Athletic Recovery now and in the future. I will use the NormaTec equipment and do so at my own risk and hereby release Opulence Mobile Athletic Recovery any damage or harm that I might incur due to use of the NormaTec equipment. IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have read and understand the foregoing Waiver of Liability, Release and Hold Harmless Agreement. Furthermore, I agree that I will comply with all instructions on the use of the Equipment and that I am using these services at my own risk.

    By signing below, I agree to the following:
    I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health.

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