Client Intake Form

Client Intake Form

The Spa at Shangri-La Springs requires all clients to fill out this form to completion.
Personal
Date of Birth*

MonthDayYear
Name*

FirstLast
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person*

FirstLast
Emergency Contact Phone Number*

Area CodePhone Number
Relationship to the Client*
Wellness Update
Do you have shortness of breath?*

YesNo
While our spa complies with State Health Department and Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the contagious diseases, we cannot make any guarantees.

Our staff are symptom-free and, to the best of our knowledge, have not been exposed to any contagious diseases. However, since we are a place of public accommodation, other persons (including other clients) could be infected, with or without their knowledge.

In order to reduce the risk of spreading contagious diseases, we ask that you answer a number of "screening" questions below. For the safety of our staff and guests, and yourself, please be truthful and candid in your answers.
Have you had a fever of 100°F or above in the last 24 hours?*

YesNo
Do you have a dry cough?*

YesNo
Do you have a runny nose?*

YesNo
Within the last 14 days, have you traveled to any foreign countries?*

YesNo
If so, where?
Please identify the foreign country
Within the last 14 days, have you traveled within the United States?*

YesNo
If so, where?
Please identify the city and state
Have you been in contact with anyone in the last 14 days who has been diagnosed with any contagious diseases?*

YesNo
Medical History

In order to plan a massage or skin care session that is safe and effective, please provide the following general information about your medical history.
Are you currently under medical supervision?*

YesNo
Are you currently taking any medication?*

YesNo
If you are currently taking any medication, please list below:
Please check all that apply:

Contagious skin conditionOpen sores or woundsEasy bruisingRecent accident or injuryRecent surgeryArtificial jointOsteoporosisCancerBack / Neck problemsCarpal tunnel syndromeSprains / StrainsCurrent feverSwollen glandsAllergies / sensitivityHeart conditionHigh or Low blood pressureEpilepsyDiabetesFibromyalgiaTennis elbowCirculatory disorderVaricose veinsAtherosclerosisPhlebitisDeep vein thrombosis / blood clotsJoint disorder / rheumatoidHeadaches / migrainesDecreased sensationTMJPregnancy
If pregnant, how many months?
Please explain the conditions you have marked from above:
Is there anything else about your health history that you think would be useful for your massage practitioner to know, in order to plan a safe effective massage session for you?
Ladies Only
Are you taking hormone contraceptives?

YesNo
Are you pregnant or trying to be pregnant?

YesNo
Are you experiencing any menopause signs?

YesNo
Are you under any hormonal replacement therapy or cancer treatment?

YesNo
If you answered yes to any of the four questions above, please explain:
History

Massage
Have you had a professional massage before?*

YesNo
If you have had a professional massage before, which style?
Do you have any difficulty lying on your front, back or side?*

YesNo
If yes, please explain:
Do you have sensitive skin?*

YesNo
Are you wearing (please check all that apply):

Contact LensDenturesHearing Aid
Do you sit for long hours at a workstation, computer or driving?*

YesNo
Do you perform any repetitive movement in your work, sports, or hobbies?*

YesNo
Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?*

YesNo
If you answered yes to the above question, please explain:
Do you have any particular goals in mind for this massage session?*

YesNo
If you answered yes, please explain your goals:
Authorization

Massage
I understand this consent form and have answered each question truthfully. I understand that the massage/bodywork I receive by the Shangri-La Springs massage therapist is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this massage session, I will immediately inform the therapist so that the pressure and / or strokes may be adjusted to my level of comfort. I further understand that the massage or bodywork should not be construed as being a substitute for a medical examination, diagnosis or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any physical or mental ailment that I am aware of. I understand that the massage therapists 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. I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapists part should I fail to do so. I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. I also understand that the Licensed Massage Therapist reserves the right to refuse to perform massage/bodywork on anyone whom he/she deems to have a condition for which massage is contraindicated.

By signing below, Client or the Responsible Party (if applicable) expressly acknowledges he/she has carefully reviewed the following and desires to proceed with receiving services upon said careful review:
1. Contact with people increases the risk of infection from contagious diseases. I am fully aware of the risks involved and give unconditional consent to receive services from this practitioner.
2. I understand and acknowledge that neither my massage therapist, the staff nor Shangri-La Springs are able to completely control the spread of contagious diseases and I have chosen to enter this facility with the understanding that the services I shall receive require close and extended contact with one or more individuals.
3. My therapist, the staff, Shangri-La Springs and it agents, employees, affiliates and parent companies shall not be liable for any exposure to contagious diseases while at this location. I am fully proceeding at my own risk.
Date*

MonthDayYear
Signature*
Type your name
History

Skin Care
Do you have any special skin problems or concerns?
Please describe
Do you use Retin-A, Renova, or Retinol / Vitamin A derivative products?*

YesNo
Have you used any alpha-hydroxy acid or glycolic acid products in the last 48 hours?*

YesNo
What skin care line(s) are you currently using?
Please list
Check any areas of concern you have regarding your skin:

Breakouts / AcneRosaceaSun spots / Brown spotsWrinkles / Fine LinesDehydrated SkinBlackheads / WhiteheadsBroken CapillariesUneven Skin ToneDull / Dry SkinSensitive SkinExcessive Oil / ShineRedness / RuddinessSun DamageFlaky Skin
Eyes

Dark CirclesPuffinessFine Lines
Please check if you have ever had an allergic reaction to any of the following:

CosmeticsAnimalsAHAsLatexMedicineSunscreensFragranceCollagenFoodPollenShellfishSeaweedOther
If you checked other above, please describe:
Have you ever had Botox, Restylane, or other injections?*

YesNo
If yes, which one?
When have you ever had Botox, Restylane, or other injections?
Please identify any other treatment goals:
Draping will be used during the session. Only the areas being worked on will be uncovered.
Authorization

Skin Care
I understand this consent form and have answered each question truthfully. I understand that withholding information from my skin care therapist may result in contraindications or skin irritation from treatments received. The skin care treatments I receive at Shangri-La Springs are voluntary and I release Shangri-La Springs from liability and assume full responsibility thereof.

By signing below, Client or the Responsible Party (if applicable) expressly acknowledges he/she has carefully reviewed the following and desires to proceed with receiving services upon said careful review:
1. Contact with people increases the risk of infection from contagious diseases. I am fully aware of the risks involved and give unconditional consent to receive services from this practitioner.
2. I understand and acknowledge that neither my massage therapist, the staff nor Shangri-La Springs are able to completely control the spread of contagious diseases and I have chosen to enter this facility with the understanding that the services I shall receive are not conducive to social distancing.
3. My therapist, the staff, Shangri-La Springs and it agents, employees, affiliates and parent companies shall not be liable for any exposure to contagious diseases while at this location. I am fully proceeding at my own risk.
Signature*
Type your name
Date*

MonthDayYear
Should be Empty:

Client Intake Form

Personal

Wellness Update

Medical History

Ladies Only

History

Authorization

History

Authorization