U&I Spa Inc

130 West 57th Street, Suite 14A
New York, NY, 10019
Phone: 917.214.9910
Email: uandispa@gmail.com

Please answer all questions below and press the [SUBMIT] button on all forms.

1. PERSONAL INFORMATION


2. MEDICAL INFORMATION

*Do you have or previously had the following? Select YES or NO

3. MASSAGE INFORMATION

By signing below, you agree to the following. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.

HOT STONE MASSAGE RELEASE FORM

Hot Stone Massage Contraindications
Hot stone massage is not suitable for everyone. There are risks associated with performing hot stone massage on individuals with the following conditions.

You must inform your massage therapist/practitioner if you have any of the following conditions which may make hot stone massage contraindicated or may require your therapist/practitioner to alter the massage.
  • Pregnancy
  • Diabetes
  • Inflammatory skin conditions
  • Open wounds or sores
  • Hypotension or Hypertension
  • Cancer (with or without treatment)
  • Varicose veins
  • Under the influence of drugs or alcohol
  • Blood clot(s)
  • Neuropathy
  • Autoimmune condition (MS, Lupus, RA, etc.)
  • Peripheral vascular disease
  • Heat sensitivity
  • Compromised immune system
  • Edema or Lymphedema
  • Cardiovascular disease
  • Client's Release
    I have read and understand the aforementioned conditions which make hot stone massage contraindicated. The massage therapist/practitioner has discussed this information with me and provided opportunity for any questions. I have disclosed any and all health risk factors.
    I understand that I will be receiving hot stone massage as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I release the massage therapist/practitioner of any and all liability for any harm that may unintentionally occur during my treatment(s).