Habitude Spa New Client

Please respond to the following questions so we can best cater to your individual needs.

By signing yearly below, you agree to the following:
1) I Give My Permission to receive massage and or spa services
2) I understand that massage and or spa services are not a substitute for traditional medical treatment
3) I understand that Spa Service Providers do not diagnose illness or injuries
4) I understand the risks associated with massage and spa services may include, but are not limited to: superficial bruising, short-term muscle soreness, exacerbation of undiscovered injury, skin breakouts or irritation, or allergic reactions

I therefore release Habitude Inc. and their staff from all liability concerning these risks that may occur during the Spa Session and understand that I or the spa provider may terminate the session at any time.

I therefore release Habitude and their staff from all liability concerning these injuries that may occur during the spa services or visit.

The questions asked help your massage therapist provide you with the best care they can, and our server is a safe, private system secure for health care records.

Signee Information

First Name *

Last Name *

Your Date of Birth *

Phone *

Email Address *

Recent Illness

Contagious Conditions

Recent Surgeries (what/when)*

Are you pregnant?*

Yes

If YES, what Trimester?

1st

2nd

3rd

Any allergies to cosmetic ingredients, medications or food? Please list.*

Do you perform any repetitive or strenuous movement in your work, hobby or sports?

Do you sit for long hours at a workstation, computer or driving?

Yes

Please describe any areas of chronic pain.*

Current Medications*

Are you taking any medications that might affect this massage, pain meds, blood pressure, etc..

Preferred Pronouns*

Please enter participants' full names:

Add Another Name

Sign Here

By clicking 'I Agree' below, you acknowledge that Habitude does not perform massage services for guests under 18 years of age, and agree that you have read and agree with the terms of the waiver and that the information you provided is accurate. You furthermore agree that your submission of this form, via the 'I Agree' button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.