Date of service

Name *

Contact Phone *

What is your occupation?

In case of emergency notify (name and contact number): *

How would you rate your health?

How did you hear about us? *

Please describe any surgeries, serious illnesses, accidents or injuries. and what areas of your body were injured?

Are you taking any medications? Which one's?

Have you ever had or are you being treated for any form of cancer?

Please explain

Are you pregnant or nursing?

Do you have heart disease?

Do you have high/low blood pressure?

Do you have a pacemaker?

Are you allergic to any oils or lotions, if so, which ones?

Are you in pain anywhere? If so where? or Do you have arthritis? If so, which joints are affected?

Do you have any other medical condition we should know about?

Do you have any other contagious diseases/symptoms? *

What would you like to accomplish with your massage today?

Did you take a covid test? *

Was it negative or positive? *

Do you have a fever or any covid symptoms? *

Have you had or been exposed to anyone with Covid -19? *

I understand that the spa services I receive are provided for the basic purpose of relaxation and relief of muscular tension. It is my responsibility to inform the therapist if I would like the pressure of my massage adjusted. I affirm that I have stated all my known medical conditions, and answered all questions honestly. I also understand that any sexually suggestive remarks or advances made by me will result in immediate termination of my session, and I will still be liable for payment of the scheduled appointment. Hanalei Day Spa (HDS), Shanti Enterprises, Darci Frankel, HCR Associates, LLC., the AOAO of Hanalei Colony Resort, Charos Corporation and its employees, independent contractors and its mortgagees shall not be liable to me or to anyone claiming under or through me for any loss and/or damage unless such loss or damages is occasioned by the gross negligence or willful misconduct of HDS et al. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by interacting with and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 while visiting Hanalei Day Spa may result from the actions, omissions, or negligence of myself and others. I acknowledge I will wear a mask all times. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with interacting with I hereby release, covenant not to sue, discharge, and hold harmless staff, their employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of their employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after interacting with Hanalei Day Spa *

CONSENT TO PROVIDE MASSAGE THERAPY SERVICES TO MINOR: By my signature below, I hereby authorize the massage therapist at Hanalei Day Spa to administer massage therapy or yoga class(es) to my child, minor or dependent, as deemed necessary by these providers