Spa Intake Form | Massages & Body Treatments

First Name *

Last Name *

Telephone *

Date of Birth *

E-mail *

Would you like to hear about promotional services & Specials?

Yes

Please list any known allergies and/or special needs. *

Please list any current medications you are taking.

Active treatment or history of Cancer *

Yes

If Yes please list

Recent Surgeries? (within the past 3 years) *

Yes

If Yes please list

Are you Pregnant? *

Yes

If yes, List Trimester

Are you breast feeding?

Yes

Massages

Do you have specific areas that you would like your therapist to focus on?

Yes

If yes, please list

Do you have any spinal problems?

Yes

Are you being treated for Diabetes?

Yes

Do you experience frequent headaches?

Yes

Area's of Concern

Stress

Insomnia

Neck/Shoulder Pain

Back Pain

Body Treatment

Check if any currently apply

Sunburn

Eczema/Dermatitis

Sensitive Skin

Open Wounds

Please read and sign where indicated

In consideration of my participation in Spa services (massage, waxing, , facials, body treatments, etc.) at The Spa at The Herrington, I hereby release, discharge and covenant not to sue The Spa at The Herrington, including their respective directors, officers, employees, agents, representatives, insurers, clients, successors, assigns, and any property owners, (“Released Parties”) and further release from liability the Releases Parties from and all claims, losses, damages, or liability, INCLUDING NEGLIGENCE, AND LOSSES DUE TO THE NEGLIGENCE OR RELEASED PARTIES WHEN PERFORMING OR INSTRUCTING ANY SPA SERVICES OR MAINTAINING THE FACILITY, (“Losses”) resulting in personal injury, accidents or illnesses (including death), and property loss, including theft, arising from, participation, in the Spa Services or using the Facility releases Parties are not able to diagnose illnesses or prescribe medical treatments or pharmaceuticals. Spa Services are not medical, and should not be considered, a substitute or diagnosis or treatment by a licensed medical professional. Guests should consult a physician requiring participation in the Spa Services and shall update Released Parties with any changes in health and Released Parties shall not be liable for failure to do so.

Personal Property

Please do not bring or leave valuables in the Facility Released Parties are not liable for any theft or loss of personal property, including jewelry or other personal items. I understand participation in the Spa Services carries certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries; my participation in the Spa Services is voluntary.

I HAVE READ AND UNDERSTAND THIS WAIVER, AND I RELEASE THE SPA AT THE HERRINGTON, AND ALL PARTIES FROM ANY AND ALL LIABILITY.I ACKNOWLEDGE THAT I AM SIGNING THIS WAIVER VOLUNTARILY.

Printed Name

Signature

Today's Date

Appointment Date

Spa Intake Form for Massages and Body Treatments