Client Intake Form
All information is held strictest confidence. At no given point is information disclosed or shared without client's written consent.
Email address *
Welcome to Noorish Spa
Thank you for choosing Noorish Spa, and filling the intake forms electronically. It saves paper and benefits the environment. Your input will be put into a PDF file and you will receive a copy by email if you choose to.
Full name *
Your answer
Your address
Your answer
City *
Your answer
State *
Your answer
Zip code *
Your answer
Phone number *
Your answer
Your Birth date *
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Date of Your appointment *
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Time of Your appointment *
Time
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Medications / Medical conditions *
Your answer
Allergies *
Your answer
Please select Ares of focus *
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Note and Suggestions
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Massage Policies
 Please turn off your cell phone for optimal relaxation.
 If at any point the session becomes sexual in nature, the session will end immediately and you will be charged for the total of the booked session.
 Please reschedule your session if you are more than 15 minutes late.
 24 hour cancellation notice is required to avoid being charged for your session.
 You will be draped and at no time will genitalia or breast tissue be exposed. We practice professional draping techniques for your comfort and ours.
 You will have a consultation with your therapist to discuss your session, disclose any medical conditions and previous injuries with your therapist to help them to understand your needs.
Client Agreement
I understand that therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.
I acknowledge that a physician be seen for that service. It is my choice to receive therapeutic massage as a form of therapy.
I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction.
I also understand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist so they adjust.
I have stated my pertinent medical conditions and will update the massage therapist of any changes in my health status. I understand that my failure to do so may pose a threat to my health and physical well being and I will not hold Noorish Spa or my therapeutic massage therapist from my liability whatsoever arising from failure on my part.
This Express Assumption of Risk Agreement and Release of Liability and Indemnity Agreement ( the “Release”), includes, but is not limited to, claims based on the following: The Spa’s amenities the Guests’ use of the Spa’s facilities, services, or equipment, and/or slipping or tripping anywhere in or about the Spa or any location in which the Sa operates, including, but not limited to public facilities. Such facilities include, but are not limited to: Locker rooms, sidewalks, Parking lots, Stairs, Whirlpool, Spa, Sauna, Steam room.
Such risk of injury includes, but is not limited to injuries arising from the participation by any of the Guests, or others in supervised or unsupervised activities at the Spa, injuries and medical disorders, including, but not limited to death, heart attacks, heat stress, sprains, broken bones, and injured muscles and ligaments, among others, arising from any recreational use of any of the Spa’s facilities, or otherwise, or while participating in any of Spa’s programs, classes, or activities, and accidental injuries occurring anywhere in or about the Spa, including its dressing rooms, showers and common areas.
I agree to the massage policy and client agreement above.
Your Signature *
Your answer
To day's date *
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