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Spa Intake Form
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Contact Information
Name
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Address
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Would you like a tour of the Farm after your treatment (or during your stay)?
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Emergency Contact Information
In case of an emergency, please provide a contact name an phone number where they can be reached.
Emergency Contact Name
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COVID-19 Screening
Please read and answer each question considering the past 14 days.
Have you had a cough?
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Yes
No
Have you had a fever?
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Yes
No
Have you had any shortness of breath?
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Yes
No
Have you had any loss of taste or smell?
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Yes
No
Have you had any (new) severe headache?
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Are you living with anyone who is sick or quarantined?
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Yes
No
Have you been around anyone exhibiting the above symptoms within the past 14 days?
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Yes
No
(Symptoms include but are not limited to cough, fever, shortness of breath, loss of taste or smell, headache, etc.)
Health & Wellness Information
Please read and answer each question to the best of your knowledge.
Have you ever had a professional massage or treatment before?
*
Yes
No
If yes, what were your favorite things you experienced from your previous massage(s)/treatments?
Do you have any difficulty lying on your front, back, or side?
*
Yes
No
If yes, please explain:
Do you have allergic reactions to oils, lotions, ointments, liniments or other substances when applied to your skin?
*
Yes
No
If yes, please explain:
Is there an area of the body where you are experiencing tension, stiffness, or other discomfort?
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Yes
No
If yes, please explain:
What are your goals for today's session?
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Are you currently under medical supervision?
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Yes
No
If yes, for what condition?
Physician's Name:
Are you currently taking any medication(s)?
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Yes
No
If yes, please list:
Are you currently or trying to become pregnant?
*
Yes
No
*If you are in your first trimester, we refrain from performing treatment unless you have a doctor's waiver. If you want to continue without a doctor's waiver, please notify your therapist.
If yes, how many weeks?
Do you smoke?
*
Yes
No
If yes, do you have any lung issues as a result?
Yes
No
If yes, please explain:
Please select any condition listed below that previously applied or currently applies to you.
Accident or Injury
Allergies (Food or Other)
Arthritis
Cancer
Circulatory Disorder
Contagious Skin Condition
Current Fever
Decreased Sensation
Diabetes
Dizziness
Easy Bruising
Epilepsy
Fibromyalgia
Headaches
Heart Condition
High or Low Blood Pressure
Injury to Head or Spine
Open Sores or Wounds
Recent or Previous Surgery
Stroke
Swollen Glands
To select multiple conditions: For Microsoft/Windows: Hold down the control (ctrl) button to select multiple options. For Mac: Hold down the command button to select multiple options.
Policies & Disclosures
Consent Agreement
*
I have read, understand and agree to all Stable Spa policies and disclosures.
I understand that massage and holistic treatments are for general wellness purposes, stress reduction, relief from muscular tension, and increasing circulation. I also understand a massage therapist / holistic practitioner must be informed of existing physical conditions. I have stated all my known medical conditions and I understand that it is my responsibility to keep my massage therapist / holistic practitioner informed of any changes in my health and any medication I may begin to take in the future. There shall be no liability on the part of the therapist, The Stable Spa or The Horse Shoe Farm if I fail to do so.
I understand that a massage therapist / holistic practitioner does NOT diagnose illness, disease, or any other physical or mental disorder. As such, a massage therapist / holistic practitioner does NOT prescribe medical treatment or pharmaceuticals and does not perform spinal manipulations. It is clear to me that my massage / holistic treatment session is not a substitute for medical examinations and/or diagnosis, and I understand that I should see a doctor or other appropriate health care provider for diagnosis and treatment of any suspected health problem.
I understand that if I am under the age of 18, that I need to be accompanied by a parent and that a parent’s signature is needed for the treatment to take place.
I understand that I will always be modestly draped, and that the massage / holistic treatment session is non-sexual. I understand that any sexual advances, references, and/or innuendos will not be tolerated. Should any of these be made I understand that I will be asked to pay for the session,
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