Spa-Nique, LLC

Pittsburgh PA

For Appointments:

Call – (412) 526-8688
          (888) SPA-NIQ9
                          772-6479
 

       

   
       
 
 

 
 

In Take Form

  
 
 
 

Last Name:

First Name:

D.O.B:

MM/DD/YYYY    

Address:

City:

State:

   Zip:

Work Phone:

999-999-9999

Home Phone:

999-999-9999

Cell Phone:

999-999-9999    

Email Address:

Emergency Contact:

Occupation/Employer:

   

How did you hear about Spa-Nique?

If Other (Please list):

The following areas of the body are typically worked on during massage.

Please check any area that you would not like massaged.
Face    Head    Neck    Upper Chest    Arms    Hands    Feet    Legs    Buttocks
Back    Abdomen

Medical History and Information

Check any or all that apply to your present health:
headaches chronic pain varicose veins
vision problems muscle or joint pain blood clots
sinus problems numbness/tingling high/low blood pressure
jaw pain/teeth grinding sprains/strains diabetes
fatigue scoliosis cancer/tumors
depression arthritis infectious disease
sleep difficulties tendonitis skin problems
 
Women only: Pregnant Painful menstruation Endometriosis
Men only: Prostrate problems    
 
List all medications/herbs/vitamins and dosage:
 
List physical activities you participate in regularly
 
What movements or activities are limited?
 
Please list recent/past injuries/accidents/surgeries
 
Have you ever received a professional therapeutic massage before?  YES    NO
If yes, date of last massage    MM/DD/YYYY
 
Are you currently receiving massages or other treatments and by whom and why? (acupuncture, physical therapy, chiropractic, naturopathic):
 
What is your main activity at work?  
On phone Sitting Computer work
Driving car Walking Other
 

Pick the description that best represents the amount of stress that you experience on a daily basis.
 
What do you do to relieve stress?
 
What do you want to get out of you session (s)?
 
 
 
 
By clicking the submit button, I agree to the following statements.

I am responsible for all charges for all services provided.  In the event that the insurance company denies benefits or makes a partial payment, I am responsible for any balance due. 

I understand the benefits and risks of massage and give my consent for massage.  I will consult my practitioner with any questions or concerns immediately. 

I understand that this is a therapeutic massage and any sexual remarks or advances will terminate the session and I will be liable for payment of the scheduled treatment.

I have stated all medical conditions that I am aware of and will keep my practitioner informed of any changes.

I further agree to communicate to my therapist in the event that there is inadequate or excessive pressure causing pain or discomfort throughout the session.
I agree to provide 24 hour cancellation notice. If I fail to do so, I agree to pay the full appointment fee.
 

 
 

≈ Gratuity Guidelines ≈

  
 

We appreciate the opportunity to serve you! Please keep in mind, as in any service business; our therapists depend on gratuities to provide them a living. When calculating a gratuity for your therapist, it is customary to tip on the regular price of your service prior to any discount being taken.

  
     
 

We thank you for your kind consideration in this matter and for visiting.

  
 
 
 
 

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