Consent Form & Liability Waiver
Luxury Massage Maui
Client Information
Legal Name
*
First Name
Last Name
Preferred Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Address of Service Location
Street Address, Unit #, City, Zip Code
Street Address Line 2
City
State / Province
Postal / Zip Code
Any special notes to gain access to location?
Is there elevator access?
Are you a Maui Resident or Visitor?
Health Data and Preferences
Have you ever had a massage before?
What type of pressure do you prefer
What areas do you need more focus on?
Are there any areas you prefer avoided?
Please list all allergies or skin sensitivities
Allergy to coconut?
Are you pregnant or breastfeeding?
Yes
No
If pregnant what trimester?
Please list current injuries
Please list current medical conditions
Consent and Waiver
*
I have disclosed all medical conditions/disorders on this form and I acknowledge it is my responsibility to update Luxury Massage Maui of any new medical conditions that arise after completing this form.
By signing this document, I understand and agree with all statements above, giving consent to Luxury Massage Maui., Licensed Massage Therapists, Assistants, Interns and Estheticians, to perform my spa services and agree not to hold any of these parties liable, releasing Luxury Massage Maui, Hawaiian Islands Luxury Massage LLC and all its affiliates, including assistants, and interns from any responsibility in case of an accident, injury, illness or adverse reactions, as a result of any services provided at the time of treatment or thereafter.
Signature
*
Electronic signatures, including typed names, shall be deemed to be the legal equivalent of a handwritten signature.
Date Signed
*
-
Month
-
Day
Year
Submit
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