MASSAGE CLIENT INTAKE FORM / WAIVER

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First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Date of Birth * +

Gender *

Emergency Contact Name *

Emergency Contact Phone # *

How did you hear about Healing Spirits Spa? *

CLIENT HISTORY

Have you had any surgery that your massage therapist should know about? *

If yes, please explain what surgery & year completed.

Rate your level of stress on a scale of 1-5; 1 being lowest, 5 being highest. *

Do you have varicose veins? *

Do you have diabetes? *

Do you have any contagious diseases? *

Do you have a thyroid condition? *

Do you have osteoporosis? *

Do you experience frequent headaches? *

Do you suffer from a herniated disk? *

Have you have any recent broken bones? *

If recent broken bone, what date?

Do you have any allergies / sensitivities? *

If allergies / sensitive; please list ALL descriptions.

Do you suffer from arthritis? *

Do you have numbness/stabbing pains? *

Do you suffer from joint swelling? *

Do you have cardiac or circulatory problems? *

Do you have high blood pressure? *

Do you suffer from epilepsy or seizures? *

FEMALES ONLY SECTION

Ladies, are you are pregnant? **You must be 14 weeks along to get a massage for momma and baby's safety"

Ladies, if you are pregnant, how far along are you?

Ladies, if you are pregnant, is the pregnancy stable?

MASSAGE QUESTIONS:

Have you ever experienced a professional massage session from a licensed massage therapist? *

Pressure for massage. *

Are you sensitive to pressure in any area? *

If sensitive to pressure, please specify location.

Check your desired modality: May not be able to accommodate late add on requests not made at booking. Dependent upon therapists ability. If not booked at time of booking, we can not guarantee that your therapist offers your requested modality! *

Would you like to add a 2nd modality? *

If yes to 2nd modality, please choose below! Dependent upon therapists ability. If not booked at time of booking, we can not guarantee that your therapist offers your requested modality!

Do you want full body massage or focus on specific areas? *

Please specify areas of focus:

List ANYTHING you do NOT want massaged? Example: FACE, FEET, HEAD, GLUTES, ETC.

Would you like to add on sugar scrub? *

Would you like to ADD CBD to your massage service for troubled area - NO THC ADDED / WE USE ISOLATE *

List any important medical information:

List any medications you are currently taking:

Optional Instructions / Questions

COVID - 19 QUESTIONS:

Have you been tested for COVID within the last 30 days? *

If yes; What were the results?

Have you been in places with a high COVID infection rate within the last 2 weeks (e.g., state-designated hotspots)? *

Are you fully vaccinated for COVID? If no, kindly wear a mask while in the building. Thank you. *

BEVERAGE

Please select your beverage of choice for AFTER your service. *

PLEASE READ WAIVER BELOW & SIGN

Agree to liability waiver presented below by Healing Spirits Spa Inc. *

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Welcome to Healing Spirits Spa & Lounge!

Non-alcoholic beverages after all services.

By booking this appointment / appointments, I understand that I must cancel / re-book all appointments associated as my point of contact within a 24 hour time period, 48 hours on select holiday dates to avoid a 50% late cancellation / no show fee with 20% gratuity charged to cover the service professional for their lost appointment time at Healing Spirits Spa. I know that all parties of 4 or more will have a 48 hour cancellation policy and require a 50% deposit at the time of booking for an established reservation. I know that I will not be honored for any missed emails requesting changes or cancellations, but to contact Healing Spirits by phone during open business hours for any booking or modifications to any appointments.

I will arrive 15 minutes early to assure that my appointment starts on time to get my full service time. If I am running late, I know that my appointment will be cut short to not inconvenience the following appointments.

I will present any other form of payment other than cash, debit or credit card to the desk before I render any services from Healing Spirits Spa & Lounge. I understand that it is my responsibility to present any coupons, vouchers, spa gift cards, gift certificates or any other form of payment before completion of any of my services. I understand that if I wait to present this information after my appointment is complete and was not mentioned at the time of booking nor prior to receiving service(s), then I will pay any difference of payment due for services received due to miscommunication on my behalf. I also understand that there are no discounts for any transactions involving payment from a gift certificate. I agree that I may only use given email / flier discounts Monday - Friday only, unless otherwise stated on flier. I will only be able to use one discount per appointment and can not be combined with any other offer. We thank the military / first responders for your service - Please take advantage of our always offering military / first responders 10% discount on Tuesdays!!

I understand that any services I have scheduled with Healing Spirits Spa may carry a risk of injury. I recognize that as a result of these services, unpredictable side effects may occur, including, but not limited too, redness of the skin, inflammation, feelings of lightheadedness, irritation of the skin, blood pressure changes, and allergic reactions.

I understand that a medical evaluation is advisable before commencing any Healing Spirits Spa service. I will continue to keep Healing Spirits Spa informed of any medical problems or change in my physical condition which may affect services that I have scheduled at Healing Spirits Spa. I acknowledge that neither Healing Spirits Spa, nor its employees are classified in diagnosing or treating medical diseases or conditions.

I expressly assume all risks to me associated with any service offered by Healing Spirits Spa, and waive any claim which I might otherwise bring against Healing Spirits Spa, its officers, directors, shareholders, employees, or contractors as a result of injuries resulting from or relating to my participation in one or more services.

Healing Spirits Spa shall not be responsible or liable for any articles lost, stolen, or damaged in (relation to) Healing Spirits Spa.

Healing Spirits Spa will not tolerate any inappropriate acts. I understand that my session will be terminated due to any form of inappropriate behavior and will be charged for the full amount of the service. We are committed to professionalism and expect the same from our clients.

I hereby authorize Healing Spirits Spa personnel to call for medical assistance for me or the below-mentioned minor and to transport the same to a medical facility or hospital in the event of an emergency. I further agree to be responsible for all costs and expenses associated with any such medical care and/or related transport and I hereby indemnify and hold harmless the Released Parties of and from any such costs.

I agree to abide by all rules and regulations as may be established from time to time by Healing Spirits Spa.  If I consume alcohol while using Healing Spirits Spa or participating in any Spa programs and Spa treatments, I represent and warrant that I am over or of the legal drinking age of 21 years old and will not remove any open alcoholic containers from the premises. I acknowledge that alcohol consumption may impair my ability to function properly, which may result in HAZARDOUS actions on my part and waive Healing Spirits Spa, its officers, directors, shareholders, employees, or contractors of any liability.

If I am executing this Release of Liability and Waiver of Rights on behalf of a minor (at least 13 years of age), I warrant and represent that I am the minor's parent or legal guardian.