Intake Form

    Name(First/Last)     Appointment Date

    Address   City   State   Zip

    Phone     Date of Birth     Occupation

    May we add you to our birthdays and specials database?

    How did you hear about us?
    Referred By:

    Emergency Contact   E/C Phone

    Do you smoke?

    Are you currently under medical supervision?

    Do you have any skin sensitivities or irritations?

    Are you currently using?

    Have you ever had?

    What is your main concern?

    What is your skin type?

    Have you ever had a professional massage before?   If yes, when?
    Goal for your massage

    It is my choice to receive spa therapies. I have completed this form to the best of my knowledge. I affirm that I have stated all known medical conditions including all known allergies or prescription drugs or products I am currently using. I agree to update AQUA Spa of any changes to my medical profile and understand there shall be no liability on the esthetician/therapist part should I fail to do so. I understand that Estheticians and Massage Therapists do not diagnose illness, disease, or physical or mental disorders, nor do they prescribe medical treatments, pharmaceuticals, or perform spinal manipulations. I acknowledge that these treatments are not a substitute for medical examination or diagnosis, and that is recommended I see a primary health care provider for that service. If I experience any pain or discomfort during my session I will immediately inform my esthetician/therapist. I give my permission to my esthetician/therapist to perform the procedures we have discussed and will hold them and AQUA Spa harmless from any liability that may result from this treatment. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my esthetician/therapist immediately.

    Electronic Signature     Date

    CONSENT TO TREATMENT OF A MINOR: By my signature below, I hereby authorize AQUA Spa's practitioner to administer massage, bodywork, or somatic therapy techniques to my child or dependent as they deem necessary.

    Signature of Parent or Guardian     Date