Name

First Name

Last Name

Cell Phone #

(###)

###

####

Date of Birth

Emergency Contact & Relationship

Emergency Contact #

(###)

###

####

Have you ever received professional massage or body work?

Yes

If yes, please specify

How much pressure do you like?

Are you currently experiencing pain from a traumatic experience (i.e. car accident, sports injuries, surgeries)?

Yes

If yes, please briefly explain (what & when)?

Are you currently taking any medications or supplements (prescription and non-prescription)?

Yes

If yes, please list names and dosage of all medications.

Are you pregnant?

Yes

N/A

If yes, what trimester?

if you selected other conditions or allergies please list or briefly explain.

Health Information *I confirm that the above information is true and accurate to the best of my knowledge and give informed consent for my services at Tanaz Hair Boutique & Day Spa. *I give my consent for my therapist to treat me for noted purposes including techniques which may be recommended. *I acknowledge that the therapist is not a physician and does not diagnose illness, disease, or any other physical disorder. *I understand that no assurance or guarantee has been provided for the reults of the service. I acknowledge that with my treatment there can be risks and they may have been explained to me and I assume those risks. i understand that the therapist must be fully aware of my existing medical conditions and will provide updates of any new issues for future services.

The information I have provided is true and complete to the best of my knowledge. If you agree please print your name and date.

Tanaz Hair Boutique & Day Spa Massage Form