Personal Information Name(Required) First Phone NumberDOBEmail Primary PhysicianEmergency ContactRelationshipPhone Medical Information Are you taking any medications?(Required) Yes No If yes, please list name and use:(Required)Are you currently pregnant?(Required) Yes No If yes, how far along?(Required)Any high risk factors?(Required)Do you suffer from chronic pain?(Required) Yes No If yes, please explain:(Required)What makes it better?What makes it worse?Have you had any orthopedic injuries?(Required) Yes No If yes, please list:(Required)Please indicate any of the following that apply to you. Cancer Headaches/Migraines Arthritis Diabetes Joint Replacement(s) High/Low Blood Pressure Neuropathy Fibromyalgia Stroke Heart Attack Kidney Dysfunction Blood Clots Numbness Sprains or Strains Explain any conditions you have marked above: Massage Information Have you had a professional massage before?(Required) Yes No What type of massage are you seeking? Relaxation Therapeutic/Deep Tissue Other Other(Required)What pressure do you prefer?(Required) Light Medium Deep Do you have any allergies or sensitivities?(Required) Yes No Please explain:(Required)Are there any areas (feet, face, abdomen, etc) you do not want massaged? Yes No Please explain:(Required)What are your goal for this treatment session?Are you experiencing any areas of discomfort on any parts of the body?(Required) Yes No If yes, what area: By signing below you agree to the following. The Spa and/or the individuals working at The Spa shall not be held liable for any damages, injuries, or adverse effects that may occur as a result of receiving services at our establishment after the period of three (3) months has elapsed from the date of service. Regardless of the nature or extent of any such adverse effects, The Spa shall bear no responsibility for any claims arising thereafter. The limitation of liability and waiver of claims as outlined in this document shall apply to all services provided by The Spa, including but not limited to body treatments, massages, facials, laser hair removal, fat freeze and any other spa services offered by The Spa. By receiving services at The Spa, you acknowledge and accept that any adverse effects or consequences that may arise after the aforementioned three (3) month period shall be your sole responsibility and The Spa and its employees shall be released from any liability. By signing below and continuing to use our services, you confirm that you have read, understood, and agreed to the terms and conditions outlined in this document. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above informations changes at any time.Client Signature & Date (m/d/y)(Required) MM slash DD slash YYYY Client Signature(Required)CAPTCHA
