Massage Client Information

Massage Client Information
Name*

First NameLast Name
Date of Appointment*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In case of emergency contact (Name & Number)*
How did you hear about us?*

Gift CardGoogle searchClient ReferralRadioDriving By
If Client Referral, who referred you? *
Age*
Gender / Pronoun*
What is your major concern or focus today?*
Are you pregnant?*

YesNo
If yes, how many weeks?
List any allergies:*
List any medications currently being used:*
List any pre-existing medical conditions, surgeries you've had and year performed:*
To the best of my knowledge, I have answered the above questions honestly.*
Type name here

Please read and initial each line below indicating your understanding of the following.
Intial here if you are pregnant
I understand the goals and limitations of massage and realize that a massage serves as no substitution for a medical examination, diagnosis, or treatment. *
Prior to receiving treatment, I have been candid in revealing any condition, medications, allergies or sensitivities, product usage, and any other pertinent information that may have impact on my treatment. *
I understand, and I am informed that, as in all health care, there are some risks to treatment, which, if applicable, will be discussed before the treatment. *
I understand that if I experience any pain or discomfort during my treatment session. I will immediately inform my therapist if the pressure and/or strokes need to be adjusted to my level of comfort.*
Because massage should not be performed under certain medical conditions, I attest that I have revealed all known medical conditions and answered all questions honestly.*
I understand that any illicit or sexually suggestive remarks or advances made by me or the use of my cell phone to take any pictures while in the massage session will result in immediate termination of the session and thus, terminating my rights to remain a client of the Spa at Springfield/Dolce Organic Salon, Med Spa & Salt Room.*
I understand that therapists at the Spa at Springfield/Dolce Organic Salon, Med Spa & Salt Room reserve the right to refuse to perform treatment on any client for any reason. *
I understand that there are certain risks to woman who are pregnant or trying to get pregnant.*
By signing below, I acknowledge that I have read and understood the above Informed Consent. I have taken the opportunity to address any questions I have regarding this Consent with a staff member of the Spa at Springfield/Dolce Organic Med Spa and my questions have been answered to my satisfaction. I have been adequately informed and wish to proceed with my treatment. As a client of the Spa at Springfield/Dolce Organic Med Spa, I hold harmless Kazar Business Ventures for any events under the care of any Spa at Springfield/Dolce Organic Med Spa employee.
Client Signature*
Date*

MonthDayYear
Date
Employee Signature
Date

MonthDayYear
Date
Should be Empty: