Spa Intake Form

Appointment Date*

MM

DD

YYYY

Appointment Time

: HH

MM

Contact Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Phone*

Sex*

Date of Birth*

MM

DD

YYYY

How did you hear about us?

Would you like to receive our spa newsletter?

Yes
No

Are you currently staying on property?

Yes
No

Would you like a tour of the Farm after your treatment (or during your stay)?

Yes
No

Emergency Contact Information

In case of an emergency, please provide a contact name an phone number where they can be reached.

Emergency Contact Name

First Last

Emergency Contact Phone

COVID-19 Screening

Please read and answer each question considering the past 14 days.

Have you had a cough?*

Yes
No

Have you had a fever?*

Yes
No

Have you had any shortness of breath?*

Yes
No

Have you had any loss of taste or smell?*

Yes
No

Have you had any (new) severe headache?*

Yes
No

Are you living with anyone who is sick or quarantined?*

Yes
No

Have you been around anyone exhibiting the above symptoms within the past 14 days?*

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?*

Yes
No

If yes, please explain:

What are your goals for today's session?*

Are you currently under medical supervision?*

Yes
No

If yes, for what condition?

Physician's Name:

Are you currently taking any medication(s)?*

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.

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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Contact Information

Emergency Contact Information

COVID-19 Screening

Health & Wellness Information

Policies & Disclosures

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+1 (828) 393-3034

Additional Info

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