PRANA/LIFE STUDIO

SPA-INTAKE FORM

First name

Last name

Phone

Date of Birth MM/DD/YYYY

What are your goals for the session?

Allergies, skin sensitivities, injuries or areas to avoid:

Prenatal/postnatal, and if so how many weeks?

I have not tested positive for any communicable illness in the past seven days and I am not currently experiencing any flu-like symptoms including body aches, sore throat, cough or difficulty breathing. I acknowledge and assume my potential risks of exposure to viruses, bacteria and pathogens by electing to receive massage therapy and I hereby waive and release my therapist and PRANA/LIFE LLC from any and all liability, past present and future, relating to the provision of bodywork.

I acknowledge that massage therapy is entirely therapeutic and non-sexual in nature and any inappropriate or suggestive remarks or actions will result in immediate termination of the session without refund, and will be prosecuted to the maximum extent of the law.

Signature

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