Chair Massage | Synergy Skin Care Spa

Service Date*

Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Occupation

Medical History

1. Are you currently under the care of a Physician?*

Yes
No

If yes, for what?

2. Are you taking any medications?*

Yes
No

If yes, please list medication and what its for (Example: Albuterol - Asthma)

3. Are you pregnant?*

Yes
No

If yes, how far along? Risk factor (low, med, or high)?

4. Please check any of the following conditions that you have*

If yes, please explain?

Massage Therapy

1. Have you had a professional massage before?*

Yes
No

If yes, how often do you receive massage therapy?

2. What type of pressure do you prefer?*

Light
Medium
Deep

3. Seated chair massage addresses your head, neck, back, arms, hands, and hips. Are there any areas you would like us to concentrate on or avoid?*

Yes
No

If yes, please explain.

4. What area do you experience pain?*

Head
Neck
Upper Back
Lower Back
Arms
Hands/Wrist
Hips

5. Are there any concerns you'd like to discuss that are not listed above?

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.

Informed Consent*

I understand this is a seated fully clothed massage.
I understand that it is my responsibility to make sure that all my questions have been addressed to my satisfaction before receiving treatment.
I understand that I will be receiving massage therapy for the purpose of stress reduction, relief from muscle tension or spasm, or for increasing circulation and energy flow.
I understand that the massage therapist does not diagnose illness, and as such, the massage therapist does not prescribe medical treatment or pharmaceuticals, nor do they perform any spinal manipulations.
It is also understood that the massage therapist reserves the right to refuse service to anyone.
I am aware that this massage is not a substitute for medical examination/diagnosis and that it is recommended that I see a physician for any ailment that I might have.
I understand and agree that I am receiving massage therapy entirely at my own risk. In the event that I become injured either direction or indirectly as a result, in whole or in part, of the aforesaid massage therapy, I HEREBY HOLD HARMLESS AND INDEMNIFY the therapist, their principals, and agents from all claims and liability whatsoever.

Name*

First Last

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*

Phone

This field is for validation purposes and should be left unchanged.

Chair Massage Treatment

Chair Massage Intake Form

Medical History

Massage Therapy

Policy & Consent