Intake form

Are You Currently Experiencing Any of the Following Conditions (or within the previous 48 hours) : *

Have you knowingly been exposed to someone who has tested positive for the Cornona Virus within the last 14 days? *

No Yes

Covid 19 Information:
During a massage session, it is not possible to maintain social distancing. You and your therapist will be sharing a treatment room in close contact with one another for an extended period of time. In an attempt to reduce the risk of spreading the Corona Virus, we ask that all visitors to Lifespa Wellness Center and their massage therapists wear a mask throughout their entire session and visit. Forehead temperatures will be taken upon entry. We ask that all visitors wash their hands or use our hand sanitizer stations upon arrival.

How are you feeling today?

In the last 5 years have you had any of the following health conditions?

If there is any additional information you'd like your massage therapist to know about your health conditions, please comment here: *

Additional Information:

The groin and breast areas will NOT be massaged. Are there any other areas, you would like your therapist to avoid? *

I consent to receiving massage. I understand that massage therapy is not a substitute for medical treatment and that no medical diagnosis will be made. I understand that any information I receive from individuals at Lifespa Wellness Center is educational in nature and is to be used at my own discretion. I understand that payment is due upon completion of each visit. I understand that cancellations or reschedules must be made 24 hours in advance, and failure to do so may result in a missed-appointment fee totaling 50% of the normal cost of the session(s).

Signature

Please enter your full name: *

Today's Date: *

Are you under the age of 18? *

If you are under the age of 18, a legal guardian's signature is required.

Guardian's full name: *

Guardian's relationship to minor *

By submitting this form you are agreeing that the information disclosed is true and correct.

If you click submit and the page does not redirect you and confirm your information has been submitted, you may have missed a required field. Not all fields are able to be highlighted if missed, such as missed check boxes.

Lifespa Wellness Center Therapeutic Massage Intake Form

Covid 19 Symptoms:

How are you feeling today?

In the last 5 years have you had any of the following health conditions?

Additional Information:

Signature