Essence Massage and Day Spa

Essence Massage and Day Spa

Intake Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
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Email*
example@example.com
Address

Street Address

Street Address Line 2

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Postal / Zip Code
Emergency Contact*

Contact NameContact Number
How did you hear about us?*

Cancellation Policy and Informed Consent
Cancellation Policy

At Essence, we truly care not only for our wonderful clientele, but also for our amazing therapists. As such, in order to minumize lost appointments for our staff, we require that cancellations be made no less than 24 hours before your scheduled appointment time. Appointments cancelled WITHIN 24 hours will incur a late cancellation fee of 40% of your scheduled service. By signing below, you verify that you agree to these terms.
Name

First NameLast Name
Informed Consent

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.

I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that massage therapists 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 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 massage therapist updated as to any changes in my medical profile during the session and understand that there shall be no liability on the massage therapists part should I fail to do so.

I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. I also understand that the Licensed Massage Therapist reserves the right to refuse to perform massage on anyone whom he/she deems to have a condition for which massage is contraindicated.
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First NameLast Name
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Essence Massage and Day Spa

Massage Preferences and Health Information

Conditions and Contraindications

Cancellation Policy and Informed Consent

Cancellation Policy

Informed Consent