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Wellness Intake Form

Welcome to Godspeed Wellness & Recovery! We're glad to have you here. Though you may be here for a specific treatment, we encourage you to consider other wellness options that could benefit you in the future. If you decide not to explore these options, please keep in mind that you’ll need a separate form for those treatments in the future. If you have any questions, feel free to contact us. Thank you for choosing Godspeed Wellness & Recovery to be a part of your wellness journey!

Wellness Intake Form & Waiver

Birthday
Month
Day
Year
How did you hear about us?

Health History & Medical Screening

Please answer the following to help ensure safe participation

Current Medical Condition(s):
Do you have any other current injuries or medical conditions?
Yes
No
Are you currently taking medications that may affect healing, bleeding, or pain sensitivity (e.g., blood thinners, steroids)?
Yes
No
Do you have any implanted devices (pacemaker, stimulator, etc.)
Yes
No
Are you pregnant?
Yes
No
Do you have skin sensitivities or allergies to adhesives?
Yes
No

Description of Wellness Services

Services Provided at Godspeed Wellness & Recovery

Your wellness session may include:

  • Soft Tissue Mobilization

  • Trigger Point Dry Needling

  • Electrical Stimulation

  • Cupping Therapy

  • Kinesiology or Athletic Taping

These services are wellness‑based, not medical treatment, and are provided under Tennessee’s direct access provisions for licensed physical therapists.

Assumption of Risk & Liability Waiver

By participating in wellness services at Godspeed Wellness & Recovery, I acknowledge and agree to the following:

  • Soft tissue mobilization, dry needling, cupping, taping, and electrical stimulation involve inherent risks, including soreness, bruising, bleeding, dizziness, skin irritation, temporary discomfort, or muscle twitching.

  • Dry needling may cause minor bleeding, bruising, soreness, or—rarely—more serious complications such as infection or pneumothorax.

  • Cupping may cause circular marks, bruising, or temporary skin discoloration.

  • Taping may cause skin irritation or allergic reactions.

  • Electrical stimulation may cause tingling, muscle twitching, skin irritation, or discomfort.

  • I have disclosed all relevant medical information, including implanted devices.

  • These services are wellness‑oriented and do not replace medical diagnosis or treatment.

  • I agree to communicate any discomfort during the session and may request to stop at any time.

  • I release Godspeed Wellness & Recovery, its owners, employees, and affiliates from liability for injuries or damages except in cases of gross negligence.

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Dry Needling Consent

I understand and consent to the use of trigger point dry needling as part of my wellness program.

I acknowledge that:

  • Dry needling uses thin, solid needles inserted into muscle trigger points.

  • Risks include soreness, bruising, bleeding, infection, and rare complications such as pneumothorax.

  • I will notify the provider if I have a fear of needles, fainting history, or medical conditions affecting bleeding or healing.

I consent to dry needling
Yes
No
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Cupping Consent

I understand and consent to the use of cupping therapy.

I acknowledge that:

  • Cupping may leave temporary marks or bruising.

  • It should not be performed over open wounds, infections, or fragile skin.

I consent to cupping
Yes
No
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Taping Consent

I understand that kinesiology or athletic tape may cause skin irritation or allergic reactions.

I consent to taping
Yes
No
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Electrical Stimulation (E-Stim) Consent

Electrical Stimulation (E‑Stim) uses controlled electrical currents to support muscle activation, reduce pain, and improve recovery. I understand that:

  • E‑Stim may cause tingling, muscle twitching, or mild discomfort.

  • It should not be used over the heart, neck, or areas with impaired sensation.

  • It is contraindicated for individuals with pacemakers, implanted stimulators, or certain cardiac conditions.

  • I will notify the provider immediately if I experience discomfort, dizziness, or unusual sensations.

I consent to Electrical Stimulation (E‑Stim)
Yes
No
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Informed Consent

By signing below, I confirm that:

  • I have read and understand this intake form and waiver.

  • I am participating voluntarily.

  • I understand these services are wellness‑based and not medical treatment.

  • I agree to follow all safety instructions provided by Godspeed Wellness & Recovery.

  • I release the provider from liability as described above.

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