Studio Soothe Pregnancy 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
Date of your service
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Month
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Day
Year
Date
Phone Number
Please enter a valid phone number. Preferably a cell that is textable for confirmations of appointments and for us to invite you in when we are ready for you.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Date of Birth
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Month
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Day
Year
Date
Therapist you have an appointment with day or your 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?
Please list any complication or condition you may have experienced during this pregnancy like: Multiple pregnancy (twins), gestational diabetes, phlebitis, placental dysfunction, high blood pressure, preeclampsia, threatened miscarriage, spotting/bleeding, premature labor, heart disease, kidney damage, blood clots?
Have you experienced any of the following complications? Please list: Varicose veins, leg cramps, dizziness/fainting, nausea/vomiting, constipation, bladder infection, hemorrhoids, swollen hands/legs/feet, difficulty sleeping?
Have you been told you are experiencing a high risk pregnancy?
Do you have any medical problems not related to your pregnancy? 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. We want to avoid the area or take proper precautions.
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?
When lying still do you get: Hot, Cold, Not sure?
What are your favorite scents? Floral, Citrus, Spice, Woody, Other?
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 this service and any others in the future if you cannot make your appointment(s) or late cancel within the 24 hour period as per our cancellation policy.
You agree to call us or email us OUTSIDE of 24 hours notice if you need to cancel your appointment(s). Cancellations must be made at a minimum of 24 hours in advance of your scheduled appointment.
You certify that you do not have any special occasions, weddings or any other important event within two weeks of this 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 the 24 hour cancellation 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. A Link is provided below for the Waiver of Liability.
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/spa with the following UNEXPLAINED 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 10 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.
Today's Date
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Signature
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