HD Skincare Solutions Client Intake Form

All information is to be confidential and held between yourself and your therapist.

History of Pathology

Please check any symptoms that apply to you and indicate right or left when applicable:

Massage Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

       • Please turn off your cell phone for optimal relaxation

       • Your scheduled session is set aside for you. We do not double book appointments

       • Please reschedule your session if you are more than 15 minutes late

       • 24 hour cancellation notice is required to avoid being charged $20 per hour for your session missed.

       • You will be draped and at no time will genitalia or breast tissue be exposed

       • You will have a consultation with your therapist to discuss your session

       • Should the session require, after your therapist has left the room, you may disrobe to your comfort level

       • I understand that my therapeutic massage therapist or I may end the session at any time for any reason

       • Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law

 

Client Agreement: 

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/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 of which I am aware.

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 given should be construed as such.

Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly.

I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.

I also understand that any illicit 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.

Understanding all of this, I give my consent to receive care.

By my electronic signature below, I agree to the massage policy and client agreement above. 

I hereby release and agree to hold Heather and Eric Davey & HD Skincare Solutions harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in any way in connection with any services received from Heather and Eric Davey & HD Skincare Solutions. I understand that this release discharges Heather and Eric Davey & HD Skincare Solutions from any liability or claim that I, my heirs, or any personal representatives may have against the salon with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Heather and Eric Davey & HD Skincare Solutions. This liability waiver and release extends to the salon together with all owners, partners, and employees.