Stretch Spa

Client Intake Form
Assisted stretching is a stretch and flexibility service that provides one-on-one stretches to enhance the quality of your life by improving your flexibility and mobility, helping your joints move through their full range of motion, improving blood flow, decreasing muscle tightness, improving your ability to perform day-to-day activities, enhancing your performance of physical activities, decreasing stress and tension in your body, and decreasing the risk of injuries. Flexibility stretching is not only important to be including in your exercise routine but also for day to day activities to experience optimal results.

Please complete this required form before your booked stretch session. By completing this form prior to your session you will be able to receive the benefit of enjoying your full stretch session instead of using any stretch time to complete this form.

If you want to purchase a stretch session please go to this link below

https://stretchfitspa.com

Thank you
Full Name*

First NameLast Name
MaleFemale
Date of Birth*

MonthDayYear
Age*
years
If Client is under the age of 18, please list parents first and last name.
Weight*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Format: (000) 000-0000.
Email (Please enter email in both fields to confirm email)*

Confirmation Emailexample@example.com
Phone callEmailTextMessengerOther
How did you hear about Natasha's Stretch Services? (If referred by someone, please mention who referred you.) Thank You*
Health and Medical
YesNo
If Yes to the question above, please list reason here.
Please list any injuries or surgeries you have had in the past 10 years. Enter none if none.*
Diabetes Type 1Diabetes Type 2AsthmaChest discomfort with exertionRapid or runaway heartbeatSkipped heartbeatShortness of breath with or without exerciseFainting or light-headednessRecent hospitalizationsOrthopedic problems, including arthritisNoneOther
If yes to any of the above, please explain here.
If you have any diagnosed health problems not mentioned above, please list the condition(s) here. Enter none if none.*
Head/NeckUpper BackShouldersArm/ElbowWrist/HandsLower BackHips/PelvisThigh/KneesHerniaNoneOther
If yes, please explain.
YesNo
Trimester 1Trimester 2Trimester 3
All personal, health and medical information is confidential between client and stretch coach.
Goals
FlexibilityHealth (General)Sports PerformanceStress/Tension ReductionPostureMobilityOther
What are the top three goals you want to accomplish, in order of importance?*
Explain why these three goals are most important to you.*
How often are you looking to stretch per week?*
1 x per week2 x's per week3 x's per week4 x's per weekother
Lifestyle
What type of life style do you have? (sedentary, active, type of work, etc.)*
Physical Activity History
YesNo
If yes, how many days a week?
Describe type of physical activity you do:*
YesNo
If yes, what sports and how often?
YesNo
Describe what you expect from receiving stretches.
Stretch Informed Consent Form
I give my consent to participate in the assisted stretching, conducted by Natasha Buffaloe (hereinafter "The Coach"). Benefits Participation in a regular stretch program has been shown to produce positive changes in a number of organ systems. These changes include increased Range of Motion, flexibility, improved performance, improved mobility and better quality of life. Risks I recognize that stretching carries some risk of soreness. I hereby certify I know of no medical problem (except those noted on this form) that would increase my risk of illness and injury as a result of participation in a regular stretch program.

I give consent to participate in an assisted stretch program conducted by Natasha Buffaloe and/or her affiliates as the stretching sessions are hands on and requires the stretch specialist to touch the client by moving the client in and out of a variety of stretches.

By signing this consent form, I understand I am personally responsible for my actions during my tenure with the stretch coach and I waive the responsibility of this coach if I should incur any injury as a result of my negligence.
YesNo
Client Signature*
Today's Date*

MonthDayYear
Date
Liability Waiver

I hereby agree that by signing this document, I consent to waive certain legal rights, including the right to sue the following party, and, if applicable, its owners, coaches, representatives, and facilities from any physical, material, tangible or intangible, loss or damages that may happen to me during my participation in any of the stretch services (hereinafter, "Stretching Services") undertaken while under their instruction or thereafter: Natasha Buffaloe (the "Stretch Provider"). I will be voluntarily participating in the Stretch Services that will be conducted by the Stretch Provider.
I agree that the Stretch Provider offers the Stretch Services with no guarantee of results. I agree that I am solely responsible to maintain the regime appropriate for my level of health and stamina, and I agree that any results that occur, whether positive or negative, are the effects of my own personal choices.I agree that participation in the Stretch Services is not a replacement for actual medical care, and that if I do experience medical issues, I will contact my doctor immediately.I agree and verify that all of the information that I have given the Stretch Provider and its representatives is accurate, up-to-date, and without the omission of any known medical issues.I agree and verify that If I have omitted any necessary personal information, whether knowingly or unknowingly, I will hold the Stretch Provider harmless against all liability for any damages that may occur to myself or to others because of my actions or inactions.I agree to keep the Stretch Provider apprised of any changes or upcoming changes concerning my physical health and personal information.I understand and agree that it is my responsibility to let the Stretch Provider know if I find myself in any pain or discomfort before, after, or during the Stretch Services.If I do require medical treatment or attention while or after participating in the Stretch Services, I agree that the medical costs are mine and mine alone and hold the Stretch Provider blameless from any charges, fees, or costs that my conditions may incur.
Please read the following:

I agree that the Stretch Provider offers the Stretch Services with no guarantee of results. I agree that I am solely responsible to maintain the regime appropriate for my level of health and stamina, and I agree that any results that occur, whether positive or negative, are the effects of my own personal choices.

I agree that participation in the Stretch Services is not a replacement for actual medical care, and that if I do experience medical issues, I will contact my doctor immediately.

I agree and verify that all of the information that I have given the Stretch Provider and its representatives is accurate, up-to-date, and without the omission of any known medical issues.

I agree and verify that If I have omitted any necessary personal information, whether knowingly or unknowingly, I will hold the Stretch Provider harmless against all liability for any damages that may occur to myself or to others because of my actions or inactions.

I agree to keep the Stretch Provider apprised of any changes or upcoming changes concerning my physical health and personal information.

I understand and agree that it is my responsibility to let the Stretch Provider know if I find myself in any pain or discomfort before, after, or during the Stretch Services.

If I do require medical treatment or attention while or after participating in the Stretch Services, I agree that the medical costs are mine and mine alone and hold the Stretch Provider blameless from any charges, fees, or costs that my conditions may incur.
YesNo
ASSUMPTION OF RISK. I understand and am aware that my participation in the Stretch Services involves risks. These risks may lead to tangible or intangible harm, and I agree that they may result not only from my own actions but also from the actions of others. With the knowledge and understanding of these risks, I choose, of my own will and volition, to continue participating in the Stretch Services. I am also aware that there are risks that I may not have considered, yet I waive my right to any claims that may occur from these unconsidered risks and I choose, of my own will and volition, to participate in the Stretch Services.

COVENANT NOT TO SUE. I will not start any lawsuit or other court action against the Stretch Provider, nor will I join any such proceeding, including any claim for money damages. I acknowledge and agree that I am entering a covenant not to sue the Stretch Provider in any capacity, including to hold the Stretch Provider liable for any injury, loss, or damage sustained by me or my property, even if it is due to the Stretch Provider's negligence or omission. I also waive the right of any of my insurers' to make any such claim.

INDEMNIFICATION: I agree to defend and indemnify the Stretch Provider and any of its affiliates (if applicable) and hold them harmless against any and all legal claims and demands, including reasonable attorney's fees, which may arise from or relate to my use or misuse of the Stretch Services or my conduct or actions. I agree that the Stretch Provider shall be able to select its own legal counsel and may participate in its own defense, if desired.

REPRESENTATION: I am over 18 (eighteen) years of age, and am medically and physically able to participate in the Stretch Services.

GOVERNING LAW: This Stretch Services Waiver shall be governed by and construed in accordance with the internal laws of Illinois without giving effect to any choice or conflict of law provision or rule. Each party irrevocably submits to the exclusive jurisdiction and venue of the federal and state courts located in the following county in any legal suit, action, or proceeding arising out of or based upon this Stretch Services Waiver.

I have read the above Stretch Services Waiver fully and I understand and agree to its contents. I understand and agree that by signing this Stretch Services Waiver I forfeit any right, claim, or ability to hold the Stretch Provider responsible for any tangible or intangible damages, loss of property, or loss of life that may occur during or after my use of the facilities and participation in the Stretch Services.
Client Signature*
Today's Date*

MonthDayYear
Date
Stretch packages end date is 30 days from date of purchase. Rescheduled sessions must be made up prior to the package end date. Must use all paid sessions before your package end date. Unused sessions will be forfeited. Stretch sessions are non refundable. Thank you.

**Prices are subject to change.
Late Policy

All in person Stretch sessions are 15, 30, 60 or 90 minutes long. All sessions start and end at your scheduled time. If you are going to be later than 15 minutes, you must call ahead or your stretch session will be forefited as a NO CALL NO SHOW.

Cancellation Policy

All cancellations must be received at least 12 hours before your scheduled Stretch session start time in order to avoid lossing session credit. Clients who do not cancel within the 12 hour notice will forfeit that session.

If you need to reschedule or cancel a session do so through the email confirmation you received when appointment was booked. If you have any diffuculty you can text Natasha at 708-243-3000.
I have read the above policies and agree to its terms as it applies to Stretch sessions.
Signature*
DRESS ATTIRE

Please were comfortable/flexible clothing. If you have on shorts/pants that are loose fitted please wear compression shorts/pants underneath. Grip socks should be worn during the stretch sessions to keep the feet from slipping during stretch movements. Regular clean socks are also ok to wear. If you have any questions please contact Natasha prior to your stretch session. Thank you.
Thank you for starting your stretch journey with me. Lets improve the way your body feels and moves.

Questions please call or text Natasha at 708-243-3000

Stretch services will be held at:

Glow Salon & Spa

3319 Vollmer Road

Flossmoor, IL 60422

https://stretchfitspa.com

Must hit the Submit button for your form to be received as complete.
Should be Empty:

Client Intake Form

Health and Medical

Goals

Lifestyle

Physical Activity History