Massage Intake Form

Name *

First Name

Last Name

Phone

(###)

###

####

Have you had a professional massage before?

Yes

No

What pressure do you prefer ? *

Light

Medium

Deep

Are you currently dealing with any of these health conditions? Check all that apply:

Carpal Tunnel*

Hight Blood Pressure

Pregnant

Sciatica

Headaches/Migraines

Firbromyalgia

Plantar Fasciitis

Joint Replacement*

Diabetes

TMJ

Cancer*

Varicose Veins

Arthritis*

Waiver and Release from Liability for Services at Willow Creek Salon and Spa. “Customer”, as noted above, does hereby waive and release, indemnify, hold harmless and forever discharge Willow Creek Salon and Spa, (hereafter referred to as “ Salon”) and its agents, employees, officers, directors, affiliates, successors, members, and assigns, of and from any and all claims, demands, debts, contracts, expenses, causes of action, lawsuits, damages and liabilities, of every kind and nature, whether known or unknown, in law or equity, that I ever had or may have, arising from or in any way related to the services being provided to me by Salon provided that this waiver of liability does not apply to any acts of gross negligence, or intentional, willful or wanton misconduct. Said services may include, but are not limited to, massage, yoga, hair removal, eyelash lift, facials, hair coloring, texture changes, permanents, well as hair cutting. I have read, understand and fully agree to the terms of this Waiver and Release. I understand and confirm that by agreeing to this Waiver and Release, I have given up legal rights. I have signed this Agreement freely, voluntarily, under no duress or threat of duress, without inducement, promise or guarantee being communicated to me. My agreement is proof of my intention to execute a complete and unconditional Waiver and Release of all liability to the full extent of the law. I am 18 year of age or older and mentally competent to enter into this Waiver and Release. By indicating "I Agree" I attest that I have read and agree to the above terms: *

I agree

I do not agree