Localized Cryotherapy Intake Form

Localized Cryotherapy Intake Form

Somatic Massage Therapy & Spa
Client Information

Intake Form
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
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MaleFemaleNon-binary / Gender DiversePrefer not to say
Birthday*

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please tell us how you heard about us:*
YesNo
Spafinder/SpaweekSomatic SpaOther
If using a gift card, please specify the value
Enter card numberUpload a photo
Please upload a photo of your gift card or gift certificate.

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HEALTH HISTORY AND PAIN MANAGEMENT INFORMATION

YesNo
Impaired sensationImpaired circulationHypersensitivity to coldAllergic reactions (urticaria)PregnancySevere hypertensionArrhythmiaPacemakerActive cancerInfectionCold-induced conditions (cold hemolysis, cryoglobulinemia, cold agglutination)Trophic disordersSensory processing disordersPolyneuropathyDeficient kidney or liver functionImpaired lymphatic systemVasculitisDiabetes-related microvascular issuesImpaired arterial blood flowChronic venous insufficiencyBlood coagulation disordersUndiagnosed lumpsRecent Botox/fillers (within 2 weeks) — aesthetic onlyOpen wounds, lesions, sunburn, or frostbite in treatment areaBleeding disordersAcute kidney diseaseAcute cardiac diseaseWounds
If you answered YES to any of the above, please explain:
What do you hope to accomplish from today's session?
Areas of Discomfort (Choose Up to "3" Total):

Please select areas of pain or discomfort you are experiencing from below (Upto 3):
Neck PainHand Pain / ArthritisFoot Pain / Plantar FasciitisHeadaches / MigrainesTMJ / Jaw PainOther
Shoulder Pain – LeftShoulder Pain – RightElbow Pain – LeftElbow Pain – RightWrist Pain – LeftWrist Pain – RightAnkle Pain – LeftAnkle Pain – RightMuscle SorenessJoint StiffnessSwelling / InflammationSports InjuryChronic PainNo Pain – General Wellness / Recovery
Upper Back PainMid Back PainLower Back PainHip Pain – LeftHip Pain – RightGlute Pain / SciaticaKnee Pain – LeftKnee Pain – RightPost-Workout Recovery
Please mark or draw on the image where you are experiencing pain or discomfort.
Therapeutic Enhancement Options

Based on your condition, the following therapies may help improve your results:
YesNo
30-Minute Clinical Therapeutic Massage - Focused pain relief for the affected area ($75)Add 100% PURE CBD Oil Enhancement to Massage - Helps reduce inflammation and discomfort ($45)Red Light Therapy - Supports tissue repair, reduces inflammation, and promotes healing ($40)Targeted Stretch Therapy - Improves mobility and reduces muscle tension ($75)Hot Stone Therapy Add-On - Enhances deep muscle relaxation and circulation ($35)I would like my therapist to recommend the best treatment

Service Enhancement

prevnext( X )

30-Minute Clinical Therapeutic Massage - Focused pain relief for the affected area

$75.00 Quantity
Item subtotal:$0.00

Red Light Therapy - Supports tissue repair, reduces inflammation, and promotes healing

$ Free Quantity
Item subtotal:$0.00

PURE CBD Oil Enhancement to Massage - Helps reduce inflammation and discomfort

$45.00 Quantity
Item subtotal:$0.00

Hot Stone Therapy Add-On - Enhances deep muscle relaxation and circulation

$35.00 Quantity
Item subtotal:$0.00

Targeted Stretch Therapy - Improves mobility and reduces muscle tension

$75.00 Quantity
Item subtotal:$0.00

Total

$0.00

Payment Methods

Credit Card

Apple Pay

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Google Pay

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Cash App Pay

After submitting the form, you will be redirected to Cash App Pay to complete the payment.

ACH Bank Transfer

Afterpay

After submitting the form, you will be redirected to Afterpay to complete the payment.

Neck Pain: Blue / Gold Upper Back Pain: Red / Black Mid Back Pain: Red / Black Lower Back Pain: Red / Black Shoulder Pain – Left: Silver / Blue Shoulder Pain – Right: Silver / Blue Elbow Pain – Left: Silver / Blue Elbow Pain – Right: Silver / Blue Wrist Pain – Left: Silver / Blue Wrist Pain – Right: Silver / Blue Hand Pain / Arthritis: Gold / Blue Hip Pain – Left: Black / Red Hip Pain – Right: Black / Red Glute Pain / Sciatica: Black / Red Knee Pain – Left: Black / Red Knee Pain – Right: Black / Red Ankle Pain – Left: Silver / Blue Ankle Pain – Right: Silver / Blue Foot Pain / Plantar Fasciitis: Gold / Blue Muscle Soreness: Blue / Silver / Red / Black (based on location) Joint Stiffness: Silver / Red / Black (based on joint) Swelling / Inflammation: Blue / Silver Sports Injury: Nozzle based on area Post-Workout Recovery: Red / Black for large muscle groups Chronic Pain: Nozzle based on area Headaches / Migraines: Gold / Blue TMJ / Jaw Pain: Gold / Blue
Recommended Cryotherapy Nozzles - Small Area (Neck, Hand/Arthritis, Foot/Plantar Fascitis, Headache/Migraine, Jaw/TMJ)
Recommended Cryotherapy Nozzles - Medium Area
Recommended Cryotherapy Nozzles - Larger Area

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Localized Cryotherapy Intake Form

Client Information

HEALTH HISTORY AND PAIN MANAGEMENT INFORMATION

Areas of Discomfort (Choose Up to "3" Total):

Therapeutic Enhancement Options

Payment Methods