Session Intake Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastAddressCity, State, Zip CodePhone *Mobile?YesNoIs it ok to text appointment reminders?YesNoEmail *AgeDOBOccupationEmergency Contact Name and Phone Number *How did you hear about us?GoogleYelpSocial Media (Instagram, Facebook, etc..)ReferralWebsiteOtherIf you selected Referral (above), please let us know who we can thank. If you selected other, please describe.Are you curtrently under a physician's care for any condition? If yes, please describe *Do you have current or history of any of the following health conditions? Check ALL that apply High Blood PressureLow Blood PressureHeart ConditionTraumatic Brain InjuryArthritisRecent ConcussionContact LensesDentures or ImplantsBlood ClotsSkin DisordersSpinal DisordersVericose VeinsRespiratory ProblemsPnemoniaCheck ALL that applyRecent Positive COVID testCurrently PregnantSurgeryRecent TraumaPlease list medical and surgery details below. If not applicable, please write "N/A" *Are you currently receiving other complementary care? (chiropractor, acupunture, etc..) *YesNoIf yes, please describe:Do you exercise or play sports regularly? *YesNoIf yes, please describeAre you taking any prescription medications? *YesNoIf yes., what kind?Do you take any supplements, herbs or vitamins? *YesNoIf yes, what kind?Primary reason for today's visit? *Areas of complaint (Pain or Tension):Are there any physical or mental conditions which the therapist should be aware of before proceeding with the treatment?Read and check each box to acknowledge *I understand that the therapist does not diagnose illnesses, diseases, or any other physical or mental disorders. In addition, the therapist does not prescribe medical treatments or pharmaceuticals.I understand that manual therapy is considered to be a contraindication for recent injuries to the head and neck and that I am not currently experiencing any of these conditions.It has been made very clear to me that Advanced Manual Therapies like craniosacral, massage, and visceral are not a subsitute for medical examination and/or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have.Because a therapist must be aware of existing physical conditions, I have stated all of my known medical conditions and take it upon myself to keep the therapist updated on my physical health. Further, I release the therapist from responsibility and liability for any adverse reactions resulting from undisclosed conditions.Late Arrival and Cancellation Policy: If you arrive more than 15 minutes late, your session may need to be shortened to avoid impact to other clients. You will still be charged for the full session. If you arrive more than 30 minutes late, the session may need to be rescheduled and you will be charged for the full session fee. A 24-hour notice is required to cancel or reschedule your appointment. Within 24-hours notice will be charged a full-session fee. In certain emergency situations, exceptions may be made on a case-by-case basis. Visit ronnibarrios.com for any additional details on our Late Arrival and Cancellation Policy.I hereby acknowledge that my typed name below will act as an electronic signature to the information provided on this form to be true and correct. *Thank you for providing your information – it allows me to give you the best care possible. Your medical information and details are not stored on this website, are kept confidential and are protected according to HIPPA guidelines. HIPPA privacy information is available upon request. Submit
