Muscle Activation Techniques Client Intake and Waiver "*" indicates required fields Step 1 of 2 50% First Name* Last Name* PhoneEmail* Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact Name* Emergency Contact Relationship* PhoneDate of Birth* MM slash DD slash YYYY Why are you seeking MAT?*Have you had MAT before?*Have you had MAT before?YesNoIf yes, with whom and when? May we contact your previous MAT specialist?*Please list all injuries and surgeries you’ve had at any point in your life.*Which other therapeutic treatments or modalities do you currently use or have you had in the past?* MAT Client WaiverMuscle Activation Techniques is a process using a systematic approach to identifying limitations in muscle contractility and re-establishing communication between affected muscle(s) and the brain. The focus of the evaluation procedure is based upon the understanding that the body will protect itself when it recognizes instability. Therefore, muscles will tighten up and lose the ability to contract effectively as a protective measure when instability is recognized. Muscle Activation Techniques addresses the component of muscle weakness as a cause for limitations in joint range of motion. When muscles are weak, and/or the communication between affected muscle(s) and the brain has become impaired, the corresponding joint(s) become unstable. This instability must be identified and addressed. Muscle Activation Techniques are designed to identify and correct the positions of instability and re-establish communication between the affected muscle(s) and the brain. When performed in this manner, the natural protective mechanisms are diminished, and normal joint motion occurs. The end result is that we are not only increasing joint motion, but, by re-establishing communication between the affected muscle(s) and the brain, we are also making sure there is increased stability throughout the range of motion (mobility and stability). The undersigned understands and agrees that during the visit he/she is not receiving physical therapy, massage therapy or chiropractic work. It is understood that Muscle Activation Techniques is the only practice employed in this session.Agreement and Consent* I Agree Signature* Type your full name as agreement and consent. Δ
