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Spa Intake Form

Appointment Date*
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Contact Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Phone*
Sex*
Date of Birth*
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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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155 Horse Shoe Farm Drive
Hendersonville, NC 28791

INFO@THEHORSESHOEFARM.COM

+1 (828) 393-3034

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