Date of service

Name

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Contact Phone

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Email address

Must be a valid email address

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Address, city, state, zip.

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What is your occupation?

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Birthday, we may send out birthday wishes (someday).

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

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How would you rate your health?

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Did you find us on yelp?

Yes
No

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Please describe any serious illnesses, accidents or injuries.

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What areas of your body were injured?

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Are you taking any medications? Which one's?

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

Yes
No

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Please explain

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Are you pregnant or nursing?

Yes
No

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Do you have heart disease?

Yes
No

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Do you have high/low blood pressure?

Yes - High
Yes - Low
No

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Do you have a pacemaker?

Yes
No

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

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Do you have arthritis? If so, which joints are affected?

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Are you in pain anywhere? If so where?

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Have you had any surgeries? Please explain.

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

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Do you have any other contagious diseases/symptoms?

Please explain in 'other box' below

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What would you like to accomplish with your massage today?

Relaxation
Work out some knots
Pain relief
Nirvana

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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 printing your name here, you are signing.

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

Parent's Signature Here

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Client Information and Waiver Form