Massage Intake General InformationName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Mobile Number(Required)Email(Required) Emergency Contact(Required) Emergency Contact Phone(Required)Your Occupation(Required) Visit Expectations and HistoryWhat is the reason for your visit today?(Required) What special areas of concern do you have?(Required) Do you have any current injuries?(Required) Do you have any previous injuries that still bother you?(Required) Do you have high blood pressure?(Required) Yes No Do you have a pacemaker?(Required) Yes No Please list any allergies, including foods.(Required) For WomenAre you currently breastfeeding? Yes No Are you currently pregnant? Yes No Maybe Have you received massage therapy during this pregnancy? Yes No Are you taking any medications? Yes No If yes, please list any medications you are currently taking: Please list any conditions/symptoms you are currently experiencing: Prenatal Care Provider/Doctor/Midwife Phone NumberMay I have permission to contact your provider, if needed? Yes No Due date MM slash DD slash YYYY Current week of pregnancy? How many pregnancies have you had? How many times have you given birth? Life and Today’s VisitIn an effort to fully customize your experience today, which scent journey would you like to have?(Required) Relax: Lavender and chamomile Restore: Lemongrass, peppermint, spearmint, and chamomile Rejuvenate: Tulsi, cardamom, and fennel How is your stress level?(Required)1 - Low2345 - HighWhat type of pressure would you like with your massage today?(Required)1 - Light2345 - DeepNote: Selecting a level 5 does not indicate you are receiving a deep tissue massage. If you would like Deep Tissue, please book that service. What are your overall health goals?(Required) Do you feel you can completely detach from the outside during this service by leaving all electronic devices in a locker? Yes No Is there anywhere you do not like to be touched? Scalp Shoulder Hands Neck Arms Chest/Decollete What size robe would you like during your service?(Required) Medium Large XL XXL 5XL Policies Refund Policy: It is our mission to provide you with the highest-quality of skin and body care products with your services. In fact, you may like these products so much that you wish to use them every day in your own home! In the event you purchase any of our spa products for home use and find them to be defective, we will exchange any products within 14 days of purchase, provided a receipt is presented. Unfortunately we cannot provide cash refunds for returned products. Instead, a spa credit will be provided for any returned products to be used on any other products or spa services available at Drift Spa. Running Late: If running late, please understand that every effort will be made to still deliver the service. However, appointments may have to be rescheduled or shortened. Cancellations: Your spa treatments are reserved especially for you. We value your business and ask that you respect the spa's scheduling policies. Should you need to cancel or reschedule, please notify us at least 48 hours in advance. Any cancellations with less than 48 hours of notice are subject to a cancellation fee amounting to the cost of the scheduled service. Guests who miss their appointments without giving any prior notification will be charged in full for the scheduled service. We recognize the time of our guests and staff is valuable and have implemented this policy for this reason. When you miss an appointment with us, we not only lose your business, but also the potential business of other guests who could have scheduled an appointment for the same time. Additionally, many times our staff will be functioning in an "on call" status and may have traveled to the spa specifically for your service. For these reasons we are obligated to compensate our staff for their time as well as make up for the lost revenue. When you schedule your appointment with us, you are agreeing to these policies. All services require a credit card or gift certificate to guarantee a reservation, so please have your credit card and/or gift certificate ready when booking. Consultations: All services begin with a thorough consultation—the most important part of the experience. We make every effort to listen and discuss exactly what our guests are expecting. As wishes are discussed, we ask our guests to voice any issues, concerns, allergies or medical conditions—we’re here for you and want you to be 100% satisfied. Our service providers will also offer product recommendations, as well as discuss routine maintenance. Before the service is performed, our skin shamans will discuss the process as well as the products that will be used. Cell Phones and Electronic Devices: We have created an atmosphere of relaxation and zen for all guests. A major part of our ritual is for you to disconnect from all outside distractions so you can connect with your mind, body and soul. For this reason all cell phones and other devices need to be turned off and kept in your locker in the restroom area. Miscellaneous and Payments: Drift Spa is not responsible for lost or stolen items or items left behind. Visa, MasterCard, American Express and Discover are all accepted methods of payment. You will be asked to give your credit card upon booking and your card will be charged the day of for all services provided, as well as a 20% service fee. You will not be presented with a bill at time of service to allow for as relaxing an experience as possible. Disclaimer and Acknowledgment: I have completed this form to the best of my knowledge and all information is true and accurate. I have disclosed all known health conditions and will inform the Massage Therapist of any changes to my health status at the beginning of future appointments. I understand that Massage Therapy does not take the place of a physician’s care. Any information changed during this service is confidential and will only be used with my consent. I release the Massage Therapist of all liability for any harm that may unintentionally occur during my treatment. I consent to the treatment and will inform the Massage Therapist immediately if I feel pain or discomfort during my session. I have read and understood all of the foregoing information.(Required) Yes No CAPTCHA Check out our spa memberships.
