Massage & Body Treatment Intake Form – soothespagrandlodge.com

Name*

First Last

Email*

Phone*

Date of Birth*

Are you wearing contacts?*

Are you pregnant?

How many weeks?

Medical Release for Prenatal Spa Treatments

Soothe Spa provides a variety of spa services, treatments, therapies and procedures. Certain Spa Treatments are not recommended for pregnant women during the first trimester of pregnancy, including massage therapy, body wraps, hot stone massage, reflexology and aromatherapy which are considered contraindicated services ("Treatments" used individually or collectively). If you are pregnant, it is suggested that you discuss receiving these services with your prenatal healthcare provider prior to receiving any such treatments.

I verify that I have discussed with my prenatal healthcare provider/physician any health concerns that I had about my participation in any Spa Treatments, including without limitation any contraindicated services listed above, and I understand and freely accept the potential risks of such Spa Treatments. I also understand that I am free to withdraw my consent and to discontinue participation in any Treatments at any time. Having read, discussed, and understood the above information, I further verify that I have obtained my prenatal healthcare provider's release and disclosed all high risk conditions of pregnancy. I do forever release the Spa, its therapists, practitioners, employees, agents, and each of their insurers, from all liability of any occur to of any nature whatsoever, whether past, present, or future for any injury or damage which may occur to myself or my family as a result of my participation in any Spa Treatments. I also agree to hold harmless and defend the Spa, its therapists, practitioners, employees and agents from all actions, claims, or other legal or administrative action that arises or may arise directly or indirectly out of my and my child's participation in any Spa Treatments.

Consent

I have read and accept the Prenatal Medical Release conditions

How did you hear about us?

For Massage Service

What areas would you like your therapist to concentrate on today?

Describe any physical complaints or problem areas:

Do you have any medical problems, previous/existing/chronic injuries, accidents or surgeries? If, so please describe them:

Do you have any allergies your therapist should be aware of (i.e. latex, coconut oil, nuts, etc.)?*

Please list them:*

I am least 18 years of age.*

Yes
No

You must be 18 years of age to receive a massage at Soothe Spa

Massage Upgrades

Our staff is dedicated to providing a luxuriously tailored treatment for you. Please see our specialty upgrades. Please note these upgrades do not add additional time to your treatment.

Please select any specialty upgrades you would like to add to your service:

Quench Massage - $15
Collagen Eye Treatment - $12
CBD Spot Treatment - $20
CBD Full Body Massage - $35
Scalp Ritual - $12

Massage Treatment Consent

I certify that the above information is complete and correct. I will keep the therapist informed of any changes as they occur. I will be responsible For making payments on any appointment which is not cancelled 24 hours in advance. I understand that Breckenridqe Grand Vacations, Soothe Spa, and any therapist working at this business will not be liable For any injuries or loss sustained to myself or property at this location, and that the procedures I am receiving are not intended to be a substitute for professional medical treatment for any condition.

Consent*

I agree to the policy

Massage Service Payment

I authorize Soothe Spa to charge the amount of my service to the credit card on file.*

Yes
No

I understand that if I do not provide the appropriate cancellation window which is 24 hours in advance of my service my card will be charged for the full cost of service.*

I agree to the policy

I understand that Breckenridge Grand Vacations, it’s employees, contractors and representatives reserve the right to refuse service to any person who fails to adhere to appropriate standards of conduct, current public health and safety standards or presents any symptoms of illness that may affect the health and safety of Breckenridge Grand Vacations employees, contractors, representatives, owners or guests.*

I agree to the policy

What is the date and time of your appointment?

I would like to include a gratuity for my service provider:

25%
20%
18%
Other

Tip Amout

Massage Services

This intake form is for clients that have already reserved with us. If you would like to book a service please call us at 970-547-8701.

Medical Release for Prenatal Spa Treatments

For Massage Service

Massage Upgrades

Massage Treatment Consent

Massage Service Payment