Massage Therapy

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birthdate*

Date

Cell Phone Number (For Text Communications)*

Please enter a valid phone number.

Email (Used only for secondary form of communication)*

example@example.com

Occupation*

Emergency Contact (First & Last Name, Phone #)*

Please list first and last name and phone number

What type of massage have you received in the past?*

NoneSwedish/RelaxationDeep TissueI'm not sure

What are your main concerns and reason for requesting massage therapy services? Please list main areas of tension and/or pain.*

Please list all allergies and sensitivities:*

DISCLAIMER: Failure to provide full and complete information may result in adverse reactions to the treatment at no fault of the therapist. Please review all contraindications and inform the therapist prior to your appointment. All information is kept private and confidential and is used only to help the therapist determine the safest course of treatment.

Please list all medications and supplements currently taken, including over-the-counter and street drugs:*

DISCLAIMER: Failure to provide full and complete information may result in adverse reactions to the treatment at no fault of the therapist. Please review all contraindications and inform the therapist prior to your appointment. All information is kept private and confidential and is used only to help the therapist determine the safest course of treatment.

Please list all past and current diagnosed medical conditions, including but not limited to: arthritis, anemia, autoimmune diseases, blood clots, broken bones, cancer, cardiac conditions, communicable disease (acute or ongoing), diabetes, fainting, headaches/migraines, nerve conditions, serious injuries, skin conditions, sleep apnea, etc. Please list as much detail as possible, including dates and whether the condition is controlled or ongoing.*

DISCLAIMER: Failure to provide full and complete information may result in adverse reactions to the treatment at no fault of the therapist. Please review all contraindications and inform the therapist prior to your appointment. All information is kept private and confidential and is used only to help the therapist determine the safest course of treatment.

Please list all past and current injuries and/or surgeries. Provide dates if possible.*

DISCLAIMER: Failure to provide full and complete information may result in adverse reactions to the treatment at no fault of the therapist. Please review all contraindications and inform the therapist prior to your appointment. All information is kept private and confidential and is used only to help the therapist determine the safest course of treatment.

List any areas where you have known bruises, abrasions, cuts, cysts or blemishes, or other areas to avoid:*

DISCLAIMER: Failure to provide full and complete information may result in adverse reactions to the treatment at no fault of the therapist. Please review all contraindications and inform the therapist prior to your appointment. All information is kept private and confidential and is used only to help the therapist determine the safest course of treatment.

Are you pregnant?*

YesNoIt's possible, but I'm not sure.

By checking the box below, I understand that I am acknowledging that massage services at Lotus Organics Day Spa & Wellness are NOT to be considered medical treatment, and that medical massage requests will be referred to the appropriate therapist(s):*

I Agree

By checking this box, I understand that there is a 48 HOUR cancelation/appointment change policy, with a late fee of up to 100% of the originally scheduled service price. (See full Cancelation Policy on the website.)*

Yes, I understand I may have to pay 100% of the originally scheduled service price if I cancel or change my appointment with less than 48 hours notice

By checking this box, I understand and agree that any illegal activity or requests for illegal activity will result in immediate dismissal and will be reported to the authorities.*

I understand and agree.

By submitting my electronic signature below, I agree that all information provided is complete and honest. I have read and agree to all policies, disclosures and disclaimers provided via www.lotusorganicsdayspa.com.

Signature* Date*

Are you sure you have read and agreed to all separate policies and disclaimers published on the website?*

No, I have not read them, but I am checking this box to acknowledge that I accept full personal responsibility for any and all outcomes resulting from future issues that may arise. I will not hold Lotus Organics Day Spa & Wellness or Lisa Parnell responsible for any adverse reactions or termination of services resulting from not adhering to the written policies.Yes, I have read and agree to all policies and disclaimers published on the website.