Name

Address

City

State

Zip

Home Phone

Children (Name and Age)

Cell Phone

Work Phone

Date of birth

Marital Status

Spouse Name

Anniversary

Primary care physician name

Who Referred You *

Please check all present symptoms related to your current condition:

Are you pregnant

Any pacemaker or ICD

Any history of bloodclots

Primary care physician phone

Where is the location of your pain

When did your complaint/symptoms begin:

To help meet your needs, please indicate your specific interests:

Describe your complaint/symptoms

What was the cause of the symptoms:

How have symptoms progressed:

Do you have any medical records that have been created :

What activity bothers you the most:

What activity lessens your symptoms:

What does your pain feel like:

Rate the intensity of your pain:

Have you seen another doctor because of your current condition?

Yes

Do you have any allergies, if so list them:

Are there any additional comments about your condition that you feel would be important for us to know:

If so, what were the results of the test :

Release of Liability

Total Body Works/ARP Wave is committed to excellence. Our goal is your complete satisfaction. Below are the terms and conditions of our program. If you have any questions or concerns, please address them with your Therapist

~ No refunds will be issued for any reason, including but not limited to; Relocation, illness, and/ or un-used sessions.

~ To provide timely scheduling of all our clients/patients- If you need to cancel or reschedule a session- it needs to be done within 24 hours of your appointed time or forfeit that session.

~ Clients/Patients arriving late will receive the remaining scheduled session time unless prior arrangements have been made with your therapist.

~ Clients/Patients will complete a Health History Form prior to their 1st treatment.

Truthful Representation:

Upon selecting the following box stating "ALL INFORMATION IS TRUE" I hereby state that all the information I have provided is true, correct and complete. If more information about my condition becomes known, I will tell the doctor when possible so that it can be added to my record:

ALL INFORMATION IS TRUE

The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

If you do not wish to e-sign, you can find a printable version here .

Release of Liability:

In conjunction with my treatment with the ARP at ARP Wave Clinic and as part of the consideration for my treatment, I, my heirs, executors, spouse, successors, assigns, offspring, agents, and representatives expressly release, hold harmless, and indemnify the ARP Wave Clinic its owners, agents, employees, representatives, assignees, licensees, and invitees, from all liability for any treatments given.

Signature *

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