Client Information Form - Retreat Spa & Salon

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This field is for validation purposes and should be left unchanged.

Name*

Email*

Phone*

D.O.B.*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Emergency Contact Name*

Emergency Contact Phone*

Have you had a professional massage before?*

Yes
No

If so, how long ago?

Conditions

Please select all that apply.

Other medical conditions

Please indicate any other medical conditions, major illnesses, broken bones, surgeries, or accidents that you have had within the past 3 years.

Current medication(s)

Allergies

Consent

I agree to the terms listed below.

I understand that the massage I receive is provided for the basic purpose of relaxation, stress reduction and relief of muscular tension. If I experience any pain during this session, I will immediately inform the practitioner so that the work can be adjusted to my level of comfort.

I further understand that the message/bodywork should not be used 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.

Because massage can be harmful under certain medical condition, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated regularly as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I forget to do so.

It is also understood that any illicit or sexually suggestive remarks or advances made by the client will result in immediate termination of the session and the client will be liable for payment in full for the scheduled appointment.