Bodeze Urban Spa Intake Form - Bodeze Urban Spa

About you

All information submitted through this form is confidential and for professional use only. Your information will not be sold or shared. Please complete this form so we may legally treat you. Thank you, The Bodeze Urban Spa team.

Name*

First Last

Address*

Street Address Address Line 2 City Province Postal Code

Email*

Date of Birth*

Phone - Primary*

Gender*

Female
Male

Phone - Secondary

Help us serve you better

Occupation*

Hobbies*

Emergency Contact Full Name*

First Last

Emergency Contact Phone*

Why are you seeking a massage therapist/what is your current concern?*

Are you visiting as the result of a motor vehicle accident?*

Yes
No

Please describe resulting injuries?*

Are you currently seeing a healthcare professional?*

Yes
No

If yes, please list names and reasons/treatments?*

Are you currently taking any medication?*

Yes
No

If yes, please list name and reason for medication(s).*

Do you have any allergies we should know about?*

Yes
No

If yes, please list your allergies?*

Are you currently pregnant or trying to get pregnant?*

Yes
No

Please review the list and check those conditions that have affected your health either recently or in the past.*

Final Step

By signing below you agree to the following.

I have stated all medical conditions that I am aware of and will keep my practitioner informed of any changes. I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so the pressure can be adjusted. I understand that massage/bodywork should not be considered as a substitute for medical examinations, diagnosis or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical aliment of which I am aware. I further understand the benefits and risks of massage and give my consent for massage. I assume all risks and responsibilities for myself and release Bod-eze Urban Spa and the therapist from responsibility from any injury or liability that may occur during treatment. I agree to provide 24-hour cancellation notice. If I fail to do so, I agree to pay the $40.00 appointment fee.

Consent*

First Last

Date*

Signature*

Intake

About you

Help us serve you better

Final Step

By signing below you agree to the following.

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