Elle Marie Spa: Massages (Including Prenatal) Waiver

Elle Marie Spa

Massage + Prenatal Massage Intake Form
Date *

Month Day Year
Date
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Email *
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
How did you hear about us?

Walked by Facebook/Instagram Online Search Referral
If referred, by who?
Your History
Have you experiences any of these health conditions in the past or present?

Hormone Imbalance Cancer/ Systemic disease High Blood Pressure Diabetes Heart problem Arthritis Auto-immune Disorder Asthma Epliepsy/Seizures Cold sores HIV/AIDS Lupus Depression/Anxiety Headaches/ Migranes None
Any known allergies? *

Asprin Latex Fruits Shellfish Lidocane Fragrance/essential oils Tree Nuts Dairy Sunscreen Pollen None
Have you ever experienced claustrophobia?

YES NO
From 1-10, rate your stress level
Are you taking birth control? If applicable

YES NO
For our pregnant guests,

Please read carefully.
PRENATAL MASSAGE RISKS & BENEFITS
Prenatal Massage Therapy Benefits - There are several observed or identified potential

benefits to massage therapy during pregnancy, including:

Relieves muscular tension, especially in the lower back, upper back, shoulders and neck
Reduces stress on weight-bearing joints
Enhances body awareness for better posture and less discomfort

Assists with body mechanics and movement during structural change Supports birth process by relaxing muscles involved in labor and birth Eases anxiety and stress during time of transition
Provides emotional support and nurturance

Prenatal Massage Therapy Contraindications – Performing massage therapy during pregnancy is contraindicated for women experiencing any of the following symptoms/signs:

Bloody discharge
Continual abdominal pains
Sudden gush or leakage of amniotic fluid
Sudden, rapid weight gain
Increased blood pressure
Protein or sugar in urine
Severe back pain that does not subside with change in position Visual disturbances
Severe nausea and/or vomiting (cannot keep anything down) Severe headaches
Excessive hunger and thirst
Increased urination in the second trimester
Fever
Diarrhea
Excessive swelling in arms or legs
Decrease in fetal movement over a 24-hour period

Additional conditions – phlebitis, thrombosis, or suspected clotting conditions, any kidney, liver or spleen compromise or infection. Local massage on areas with severe varicose veins and swelling are avoided due to clotting risk.

Prenatal High-Risk Pregnancies

It is a strict policy of Beyond Exercise to require a doctor’s release form in order to receive massage therapy during a High-Risk Pregnancy, which includes, but is not limited to:

Early labor, miscarriage threat, placental or cervical dysfunction Gestational Edema Proteinuria Hypertension (GEPH) Preeclampsia
Gestational Diabetes

Pre-existing cardiac, renal, connective tissue or liver disorders/diseases Fetal genetic disorders
Complications in previous pregnancies
Three or more miscarriages
Are you pregnant or breast-feeding?

YES NO
Did you read the above benefits and risks?

YES NO
Are you experiencing any of the risks as outlined above?

YES NO
Do you consent to us performing a massage at this time for you?

YES NO
Your Service

Pick your experience
Conversation preferences

I prefer to discuss my goals during our treatment and be informed of what you’re applying to my skin. I prefer to relax and keep conversation to a minimum.
Your Promise
I acknowledge that I must adhere to Elle Marie Spa's policies:

Cancellations: We allow cancellations 24 hours prior to your appointment. Cancellations less than 24 hours will result in a 50% charge and a No Show will result in a 100% charge on your gift card or credit card.

Check In: Please check in at least 10 minutes prior to your reservation. If you arrive late for your appointment, you risk having your appointment shortened so that we can accommodate the next scheduled guest.

Gratuities: The price of your service does not include gratuity. We recommend a 15% to 20% gratuity for your service provider.

We thank you in advance for respecting these and look forward to making your day amazing!
I agree
I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions. I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm. I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied. I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment. I acknowledge that (if applicable) if I am pregnant, I have read all the benefits and contraindications of a prenatal massage and am aware of the risks of a high risk pregnancy and what that means by going ahead with my service. I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments I release Chateau Glow and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.
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Elle Marie Spa

Your History

For our pregnant guests,

Your Service

Your Promise