Studio Soothe Massage Consent Form
PLEASE USE TAB KEY TO MOVE TO THE NEXT BOX AFTER ENTERING YOUR INFORMATION. PRESSING “ENTER” OR “RETURN” WILL SUBMIT AN UNFINISHED FORM. THANK YOU!
Name
First Name
Last Name
Actual Date of your service
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Month
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Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number. Preferably a cell that we can text you for appointment confirmation and to invite you inside when we are ready for you.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
Therapist you have an appointment with day of treatment. Say N/A if you don’t know
Who do we thank for telling you about us?
Have you had a massage before? If so, when was your last one?
Are you pregnant? If you are pregnant and you are not scheduled for a pregnancy massage you must be. Please contact us ASAP at 415-674-7511. Even if you are in your first trimester it is very important to you and your child's health and safety to make sure we are using proper techniques and props for your condition.
Do you have any medical problems? If so please explain
In the last year have you been under a Dermatologist care? If so, for what skin conditions.
Do you have any warts? (Most people don’t realize these are contagious) This will not affect whether you receive your service or not. We would need to take precaution or avoid the area.
Have you had any surgery or serious illness in the last year?
Please list any medications you are taking.
Are you allergic to Latex, any products, oils or foods? (Like nuts?) If so what was your reaction to them?
When getting a massage, the pressure(s) you prefer: Deep, Medium, light, Not sure?
What are your favorite scents? Floral, Citrus, Spice, Woody, Other?
When lying still do you get: Hot, Cold, Not sure?
Is there anything you’d like us to know to make your service better for you?
Please initial the following statements
You understand you are responsible for payment of 100% of the cost of the service now and in the future if you cannot make your appointment(s) or cancel inside of the 24 hour window of your scheduled appointment:
You agree to call us or email us outside of 24 hours notice if you need to cancel your future appointment(s):
You certify that you do not have any special occasions, weddings or any other important event within two weeks of your scheduled appointment. You totally understand that skin care, massage therapy and waxing can potentially cause skin reactions and Studio Soothe cannot be held responsible for any reaction you may have as a result of your service. If you wish to reschedule, you may do so outside of our 24 hour cancellation policy window.
I understand that if I choose to still have my appointment within two weeks of my “special event” as listed above, Studio Soothe will ask that a Waiver of Liability be Filled out and signed after the completion of this form. Please see link below after completion of this form.
You understand that massage therapy, or any spa modalities cannot replace the care of a qualified medical doctor:
You understand if you are verbally abusive or sexually suggestive to anyone at Studio Soothe you will be charged the full amount of the scheduled service and will be asked to leave:
If you have Eczema or Psoriasis or any other skin disorder, you acknowledge that massage can cause irritation to your disorder and you agree to take full responsibility for any reaction you have with your own doctor:
You understand that you are a participant at Studio Soothe and while our massage therapists will check in with you it is up to you to communicate with us if we are using too much pressure, if you are too hot or cold or if any of our products don’t feel right to you. You agree that you should be getting what you want and will communicate with us what is happening with you during your service. (We are here to help!)
If you are unhappy with your practitioner, your service or any other issue you have with Studio Soothe, you agree to contact us via email or phone call to let us know (Because we want to get it right! Thanks!)
Please initial that you are 18 years of age at the time of this service.
I knowingly and willingly consent to having Massage service(s) now and in the future during the COVID-19 pandemic.
To prevent the spread of contagious viruses and to help protect each other, I understand that I will have to follow the Studio Soothe’s strict COVID-19 guidelines. https://www.studiosoothe.com/covid19-information
I agree not to come to the salon if I’ve had any of these symptoms UNEXPLAINED within 24 hours of your service. Symptoms of COVID-19 listed below: Fever, Temperature, Shortness of breath, Loss of sense of taste or smell, Dry cough, Runny nose, Sore throat. If I have any of these Unexplained symptoms I will call Studio Soothe asap 415-674-7511 to reschedule my appointment at no charge. Please help us after 7 months of closure to do this as soon as you possibly can. We much appreciate the help and effort.
I verify I have not traveled outside the United States In the past 14 days before the date of my service.
I understand that while Studio Soothe is in compliance with city/ county/ state guidelines and diligent in their Capacity limits, Proper PPE and cleaning that entering any facility is a risk and we cannot guarantee you will not contract COVID-19.
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