Client Intake Form | HUSH Recovery Studio

1

Client Information

Your contact and identification details.

Name *

Date of Birth *

Phone Number *

Email *

2

Intake Checklist - General Health Conditions

Please check all that apply. Items listed below are screening considerations and are not necessarily absolute contraindications.

General Health Conditions - Continued

I have active skin infections, open wounds, or inflammation in the areas of treatment. I have had recent surgery or injuries in the areas of treatment. I am using HBOT or ozone therapy. I am using methylene blue or similar mitochondrial-support supplements (please describe below).

Description / notes:

3

Medications and Supplements

Please select all that apply and list medications or supplements currently used.

I am currently taking thyroid medication. I am taking injectable insulin or other diabetic prescription medication. I am taking blood-thinning medication (e.g., warfarin). I am taking photosensitizing medication(s). Please list below.

Other medications or supplements currently used:

Medication / Supplement	Dose

4

Acknowledgment of Risks

I understand the potential risks of red light therapy, including skin irritation, photosensitivity, or effects on thyroid function. I have been advised to avoid direct exposure of red light to my eyes without protective goggles. I have been informed that these therapies are not a substitute for professional medical advice, diagnosis, or treatment.

5

Marketing Consent - Mandatory Selection

I consent to HUSH Recovery Studio using my results for marketing and promotional purposes. I do not consent to HUSH Recovery Studio using my results for marketing and promotional purposes.

6

Legal Waiver and Consent

Please read the waiver and certification before signing.

By signing below, I acknowledge that I have read and fully understand the potential risks and contraindications associated with red light therapy (635 nm) and vibration therapy. I certify that:

I have disclosed all relevant medical conditions, medications, and treatments as requested in this form.
I understand that red light and vibration therapy may have side effects, including but not limited to skin irritation, muscle soreness, dizziness, or interactions with my current medications or conditions.
I agree to use this equipment voluntarily and assume full responsibility for my own health and safety during the therapy sessions.
I agree that there are no refunds allowed.
I hereby waive, release, and hold harmless HUSH Recovery Studio, its employees, contractors, and affiliates from any and all claims, liabilities, or damages arising out of or in connection with my use of the equipment and therapy sessions.
This waiver and release of liability apply to all past, present, and future sessions unless revoked in writing.

Client Certification

I confirm that the information I have provided is accurate and complete to the best of my knowledge, and I have had the opportunity to ask questions before signing.

This form is intended for client intake and informed consent. It does not replace evaluation or advice from a licensed medical professional. If you have questions about whether photobiomodulation is appropriate for you, consult a qualified healthcare provider.

7

Signature and Date

Typing your full name records your digital acknowledgement for this submission.

Client Signature: *Type your full name to sign electronically.

Date:

17 October 2026