Customer Intake

First Name

Last Name

Mobile Phone

Address

City

State

Zip

Birthdate

Occupation

Explain any of the above and/or any other concerns, or any instructions you have: (optional)

I agree with these policies: (optional)

Our establishment requires all clients to be properly draped at all times.
Breast massage is strictly prohibited.
Massage can include glutes and abdominal work. Please let your LMT know your comfort level.
If you are uncomfortable at any time, ask the therapist to stop and your session will end. If your therapist is uncomfortable at any time, he/she will end your session as well.

I further agree with the following: (optional)

It is also understood that any elicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension.
If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort.
I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment that I am aware of.
I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session should be construed as such.
Since massages/bodywork may be performed under certain medical conditions, I affirm that I have reported all my known medical conditions, and answered all questions honestly. I agree to update front desk staff and practitioner if there are any changes in my medical profile and I understand that there shall be no liability on the practitioners and spa part should I forget to do so.

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