Client Intake Form

Client Intake Form

For all spa services, you will be required to fill out this form to completion.
Personal
Date of Birth *

Month Day Year
Name *

First Last
Phone Number *

Area Code Phone Number
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact Person *

First Last
Emergency Contact Phone Number *

Area Code Phone Number
Relationship to the Client *
COVID-19
While our spa complies with State Health Department and Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees. Our staff are symptom-free and, to the best of our knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other clients) could be infected, with or without their knowledge.

In order to reduce the risk of spreading COVID-19 we ask that you answer a number of "screening" questions below. For the safety of our staff and guests, and yourself, please be truthful and candid in your answers.
Have you had a fever of 100°F or above in the last 24 hours? *

Yes No
Do you have shortness of breath? *

Yes No
Do you have a dry cough? *

Yes No
Do you have a runny nose? *

Yes No
Within the last 14 days, have you traveled to any foreign countries? *

Yes No
If you have traveled to any foreign country in the last 14 days, where?
Within the last 14 days, have you traveled within the United States? *

Yes No
If you have traveled within the US in the last 14 days, where?
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus symptoms? *

Yes No
Medical History

In order to plan a massage or skin care session that is safe and effective, please provide the following general information about your medical history.
Are you currently under medical supervision? *

Yes No
Are you currently taking any medication? *

Yes No
If you are currently taking any medication, please list
Please check all that apply

Contagious skin condition Open sores or wounds Easy bruising Recent accident of injury Recent surgery Artificial joint Osteoporosis Cancer Back / Neck problems Carpal tunnel syndrome Sprains / Strains Current fever Swollen glands Allergies / sensitivity Heart condition High or Low blood pressure Epilepsy Diabetes Fibromyalgia Tennis elbow Circulatory disorder Varicose veins Atherosclerosis Phlebitis Deep vein thrombosis / blood clots Joint disorder / rheumatoid Headaches / migraines Decreased sensation TMJ Pregnancy
If pregnant, how many months?
Please explain the conditions you have marked from above
Is there anything else about your health history that you think would be useful for your massage practitioner to know, in order to plan a safe effective massage session for you
Ladies Only
Are you taking hormone contraceptives?

Yes No
Are you pregnant or trying to be pregnant?

Yes No
Are you experiencing any menopause signs?

Yes No
Are you under any hormonal replacement therapy or cancer treatment?

Yes No
If you under any hormonal replacement therapy or cancer treatment, please explain
History

Massage
Have you had a professional massage before? *

Yes No
If you have had a professional massage before, which style?
Do you have any difficulty lying on your front, back or side? *

Yes No
If you have any difficulty lying on your front, back or side, please explain
Do you have sensitive skin? *

Yes No
Are you wearing (please check all that apply):

Contact Lens Dentures Hearing Aid
Do you sit for long hours at a workstation, computer or driving? *

Yes No
Do you perform any repetitive movement in your work, sports, or hobby? *

Yes No
Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort? *

Yes No
If there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort, please explain
Do you have any particular goals in mind for this massage session? *

Yes No
If you have any particular goals in mind for this massage session, please explain
Authorization

Massage
I understand this consent form and have answered each question truthfully. I understand that the massage/bodywork I receive by the Shangri-La Springs massage therapist is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this massage session, I will immediately inform the therapist so that the pressure and / or strokes may be adjusted to my level of comfort. I further understand that the massage or bodywork should not be construed as being a substitute for a medical examination, diagnosis or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any physical or mental ailment that I am aware of. I understand that the massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of the session should be construed as such. I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapists part should I fail to do so. I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. I also understand that the Licensed Massage Therapist reserves the right to refuse to perform massage/bodywork on anyone whom he/she deems to have a condition for which massage is contraindicated.

By signing below, Client or the Responsible Party (if applicable) expressly acknowledges he/she has carefully reviewed the following and desires to proceed with receiving services upon said careful review:
1. Contact with people increases the risk of infection from COVID-19. I am fully aware of the risks involved and give unconditional consent to receive services from this practitioner.
2. I consent to my name and contact information being shared with the state and/or federal health officials, in order to assist with contact tracing requirements of COVID-19 regulations. Disclosure requirements vary, but information shall only be released if certain governmental criteria are met.
3. I understand and acknowledge that neither my massage therapist, the staff nor Shangri-La Springs are able to completely control the spread of COVID-19 and I have chosen to enter this facility with the understanding that the services I shall receive are not conducive to social distancing.
4. My therapist, the staff, Shangri-La Springs and it agents, employees, affiliates and parent companies shall not be liable for any exposure to COVID-19 while at this location. I am fully proceeding at my own risk.
Signature *
Type your name
Date *

Month Day Year
History

Skin Care
Do you have any special skin problems or concerns?
Please describe
Do you use Retin-A, Renova, or Retinol / Vitamin A derivative products? *

Yes No
Have you used any alpha-hydroxy acid or glycolic acid products in the last 48 hours? *

Yes No
What skin care line(s) are you currently using?
Please list
Check any areas of concern you have regarding your skin:

Breakouts / Acne Rosacea Sun spots / Brown spots Wrinkles / Fine Lines Dehydrated Skin Blackheads / Whiteheads Broken Capillaries Uneven Skin Tone Dull / Dry Skin Sensitive Skin Excessive Oil / Shine Redness / Ruddiness Sun Damage Flaky Skin
Eyes

Dark Circles Puffiness Fine Lines
Please check if you have ever had an allergic reaction to any of the following:

Cosmetics Animals AHAs Latex Medicine Sunscreens Fragrance Collagen Food Pollen Shellfish Seaweed Other
If you checked other above, please describe
Have you ever had Botox, Restylane, or other injections? *

Yes No
If you ever had Botox, Restylane, or other injections, which one?
If you ever had Botox, Restylane, or other injections, when?
Treatment goals
Draping will be used during the session. Only the areas being worked on will be uncovered.
Authorization

Skin Care
I understand this consent form and have answered each question truthfully. I understand that withholding information from my skin care therapist may result in contraindications or skin irritation from treatments received. The skin care treatments I receive at Shangri-La Springs are voluntary and I release Shangri-La Springs from liability and assume full responsibility thereof.

By signing below, Client or the Responsible Party (if applicable) expressly acknowledges he/she has carefully reviewed the following and desires to proceed with receiving services upon said careful review:
1. Contact with people increases the risk of infection from COVID-19. I am fully aware of the risks involved and give unconditional consent to receive services from this practitioner.
2. I consent to my name and contact information being shared with the state and/or federal health officials, in order to assist with contact tracing requirements of COVID-19 regulations. Disclosure requirements vary, but information shall only be released if certain governmental criteria are met.
3. I understand and acknowledge that neither my massage therapist, the staff nor Shangri-La Springs are able to completely control the spread of COVID-19 and I have chosen to enter this facility with the understanding that the services I shall receive are not conducive to social distancing.
4. My therapist, the staff, Shangri-La Springs and it agents, employees, affiliates and parent companies shall not be liable for any exposure to COVID-19 while at this location. I am fully proceeding at my own risk.
Signature *
Type your name
Date *

Month Day Year
Should be Empty:

Client Intake Form

Personal

COVID-19

Medical History

Ladies Only

History

Authorization

History

Authorization