Chair Massage Treatment

Thank you for taking the time to fill out this form for the upcoming massage. We’re looking forward to providing you with the ultimate spa experience.   All of the information provided is confidential and will only be shared with the technician performing your service. Your privacy and safety is our utmost concern. Please feel to contact us if you have any questions. 

Chair Massage Intake Form

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Medical History

  • Massage Therapy

  • Policy & Consent

    At Synergy Mobile Spa, it is our intention to provide our guests with professional and therapeutic services in a relaxing and friendly environment; we will tailor each treatment to our client’s individual needs. If you experience any pain or discomfort during the session, you will immediately inform the therapist so that the pressure and/or strokes may be adjusted to your level of comfort. In addition, you understand that services provided are NOT a substitution for a medical examination, diagnosis or treatment by a medical or chiropractic physician or other healthcare specialist.
  • I have read and fully understand the terms within the above policies and consent. I certify that all of the above information is true and to the best of my knowledge. I understand and agree with the policies. By signing this form, I waive any and all claims, damages, action and liabilities against Synergy Skin Care & Spa, LLC (dba Synergy Mobile Spa) arising out of or relating to massage therapy, hand/foot treatments, skincare and allergic reactions to services performed. In the event a dispute arises over the outcome of my procedure, I consent solely to arbitration as a legal means of settlement. I understand English, or if I do not, I have appointed someone to translate this consent form in its entirety. I am eighteen years of age (18) or older.
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.