Wufoo

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Date * MM / DD / YYYY
Today's Date
Your Name * First Last
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Number ### - ### - ####
Cell Number ### - ### - ####
Emergency Contact Name * First Last
Emergency Contact Phone Number * ### - ### - ####
Email Address

You’re email address will be completely safe and will not be shared!
Please tell us how you heard about Gentle Illumination Group. (List your friend if you were referred.) *
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We know you're here for relaxation. Please explain any other reason for seeking massage or other services at this time. (ie. lower back pain, weight loss)
Please check any of the conditions/issues below that apply. *
Asthma / Lung Problems Allergies Arthritis Athletes Foot Blood Clots Bruise Easily Cardiac / Circulation Problems Constipation / Diarrhea Currently Under Dr. Care Diabetes Epilepsy Fractures Headaches / Migraines Herniated / Bulging Disks High Blood Pressure High Stress Jaw Pain/TMJ Low Blood Pressure Lung / Breathing Problems Muscular Conditions Muscle Tension / Soreness Numbness / Tingling Physical Tension / Pain From Injury Recent Injury Sensitivity to Pressure Spinal Problems Surgery Varicose / Spider Veins Wear Contact Lenses None of the Above
If any of the items were selected above, please briefly explain here.
Please list and explain any medications you are taking at this time :
N/A
Massage is contra-indicated under certain conditions. For your safety, please be completely honest prior to the start of this or any massage session.
Check any of the following if they apply to you. *
Fever Flu Infection/Infectious Disease Inflammation Open Cuts/Sores Skin Conditions None of the above
If you are a woman, are you currently pregnant?
Yes No
If pregnant, how far along are you? Also, do you have difficulty resting on your front?
Disclaimer and Discloser Information

PLEASE READ ENTIRE SECTION BELOW BEFORE SIGNING
I have stated all conditions that I am aware of and this information is true and accurate to the best of my knowledge.

I will inform my health care provider, esthetician, and/or massage therapist of any changes in my status.

I understand that the massage / bodywork / esthetic services I receive is for the purpose of stress reduction, skin benefiting and /or the relief from muscular tension, spasm or pain and to increase circulation.

If I experience any pain or discomfort, I will immediately inform my therapist so that the pressure and / or other methods can be adjusted to my comfort level.

I understand that if seeking massage, my therapist does not diagnose illness or disease, nor perform any spinal manipulations, and does not prescribe any medications other than for my skin (if esthetic services).

I completely acknowledge that massage and esthetic services are not a substitute for a medical examination or diagnosis and that I should see my health care provider for those services.

If I am unable to attend my future scheduled appointment(s), I will respect and abide by the set cancellation policies, or risk being charged or losing the discount for services through my pre-paid deal or voucher. (I prefer 24 hour notice, but will accept as little as 2 hours or less in an emergency.)

I understand that I am receiving massage therapy and esthetics services at my own risk. In the event that I become injured either directly or indirectly as a result, in whole or in part, of the aforesaid services, I hereby hold harmless and indemnify the therapist, their principals, and agents from all claims and liability whatsoever.

SEXUAL ADVANCES, REQUEST FOR SEXUAL FAVORS, ALL OTHER VERBAL/ PHYSICAL CONDUCT AND/OR BEHAVIOR OF A SEXUAL NATURE WILL CONSTITUTE AS A BREACH OF THIS AGREEMENT; IS SEXUAL HARASSMENT AND AGAINST THE LAW.

ANY OF THE ABOVE MENTIONED WILL NOT BE TOLERATED!
By typing my first and last name here, I acknowledge that I have read, understand and agree with the information above. *
Do Not Fill This Out

Wufoo

Help us help you

Massage is contra-indicated under certain conditions. For your safety, please be completely honest prior to the start of this or any massage session.

Disclaimer and Discloser Information