U&I Spa Inc

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

1. PERSONAL INFORMATION

*Name

*AddressStreet Name, #, City, State, ZIP

*Birthdate

*Phone Number

*Emergency Contact Phone Number

*Relationship

*Email

Who is your Primary Physician?

How did you hear about us?

2. MEDICAL INFORMATION

*Are you taking any medication?

Yes

No

*If Yes, please list medications you are taking below

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

*Are you currently pregnant?

Yes

No

*If yes, how far along? Any high risk factors?

*Do you suffer from chronic pain?

Yes

No

*If yes, please explain why? What makes it better or worse?

*Have you had any orthopedic injuries?

Yes

No

*If yes, please list injuries:

Explain any conditions you have marked above:

3. MASSAGE INFORMATION

*Have you had a professional massage before?

Yes

No

*What type of massage are you seeking?

Relaxation

Therapeutic/Deep Tissue

Other

If you chose Other, please explain:

*What pressure do you prefer?

Light

Medium

Deep

*Do you have any allergies or sensitivities?

Yes

No

Please list allergies or sensitivities:

*Are there any areas of discomfort you do not want massaged?

Yes

No

Please list areas (left or right arm, shoulder, feet, face, abdomen, etc.):

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.

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).

*Please check the following that applies to you:

I understand the information contained on this form and confirm that I do not have any of the above conditions.

My condition(s) is/are listed above and therefore make(s) hot stone massage contraindicated. Given this knowledge I hereby give my full consent to receive hot stone massage and take full responsibility of any side effects or harm that may come from my receiving hot stone massage.