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4860 N. Clark St, Chicago, IL 60640

773.675.1918

www.revivemassagechicago.com

 

Massage - New Client Intake Form

I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or techniques may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, Chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions/injuries and that I am not under the influence of alcohol, pain medication, muscle relaxers or any other substance that would alter my sensitivity or ability to feel pain. I have answered all questions honestly and agree to keep the practitioner updated as to any changes in my general health. Should I choose the CBD Enhancement, I understand that CauseMedic CBD Massage Cream contains cannabidiol (CBD) derived from the hemp plant. I acknowledge that the CBD in this product is intended to provide relief from muscle soreness and inflammation and is not intended to diagnose, treat, cure, or prevent any disease. I am aware that the use of CauseMedic CBD Massage Cream does not guarantee any specific health benefits. Additionally, I understand that this product contains no THC, and is not psychoactive.

I agree to hold harmless and fully discharge and release forever and all time the officers, directors, employees, staff members, agents, contractors, successors and assign of Revive Medspa LLC, Revive Massage Chicago LLC, Revive Skin Care & MedSpa LLC, and Revive MSO LLC from any costs, expenses, or other liability whatsoever, including but not limited to attorneys' fees, compensatory, punitive, exemplary, consequential and special damages of any kind whatsoever, resulting from the service I have voluntarily chosen to undergo and any condition or result, known or unknown, that may arise as a result of such procedure or any other treatment I receive. As of May 4, 2024, I am of lawful age (18) and have read and fully understand the contents of this document and represent myself as physically capable of using the service offered by Revive Massage Chicago LLC.

Inappropriate Guests

Please remember that all Revive Massage Therapy & Spa therapists and other staff are licensed by the State of Illinois and are experienced professionals here to provide you the highest level of service. We ask that in return you treat them with the same respect they will extend to you and refrain from any inappropriate actions, requests, or comments that may be viewed as harassing or intimidating. It is our goal to ensure all services are performed in a professional environment

Effective October 24th, 2017 the Illinois Massage Act Ordinance MCC4-6-320 requires us to inform all prospective clients with the following written notice: Illinois State law prohibits soliciting another for the purpose of a sexual act. Solicitation can be punishable as a Class 4 felony, subjecting an offender to fines and imprisonment, and impoundment of any vehicle used by the offender to commit the offense. We immediately report all offers or requests to buy sexual services to law enforcement.

Cancellation Policy: Our Team of Licensed Professionals are only paid when they provide a service and only come to work when they have an appointment, so it is imperative that you provide us with at least 24 hours notice should you need to change or cancel your appointment. It is how they make a living and provide for themselves and families. Your appointment is reserving time on their calendar and it is preventing another client from doing the same. All that we ask is that you extend the courtesy to notify us in a timely manner (24 hours) should something change and you are unable to keep your appointment. If you cancel the same day or fail to show up for your appointment, your credit card that you provided to make the reservation will be charged for the entire amount of the service and you will be required to pre-pay for any future appointments, including past missed appointments. If you have an outstanding gift certificate, package credit or reward points, it will be redeemed for your missed appointment.By signing this document, you agree to and understand our cancellation policy and forfeit any right to dispute/reverse or otherwise deny a credit card transaction.

Product Sales/Gift Cards/Gift Certificates/Packages: All product sales are final and are non-refundable. In addition, Gift Certificates/Gift Cards and Packages for all services are non-refundable regardless if they were purchased online or in-store.

 



First Client's Name

First Name*

Middle Name

Last Name*
First Client's Date of Birth*
First Client's Signature*
Second Client's Name

First Name*

Middle Name

Last Name*
Second Client's Date of Birth*
Third Client's Name

First Name*

Middle Name

Last Name*
Third Client's Date of Birth*
Fourth Client's Name

First Name*

Middle Name

Last Name*
Fourth Client's Date of Birth*
Fifth Client's Name

First Name*

Middle Name

Last Name*
Fifth Client's Date of Birth*
Sixth Client's Name

First Name*

Middle Name

Last Name*
Sixth Client's Date of Birth*
Seventh Client's Name

First Name*

Middle Name

Last Name*
Seventh Client's Date of Birth*
Eighth Client's Name

First Name*

Middle Name

Last Name*
Eighth Client's Date of Birth*
Ninth Client's Name

First Name*

Middle Name

Last Name*
Ninth Client's Date of Birth*
Tenth Client's Name

First Name*

Middle Name

Last Name*
Tenth Client's Date of Birth*
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Client Contact Information:

Cell Phone Number (no dashes): *

Referred by:
Emergency Contact

Emergency Contact *

Emergency Contact Phone *
General Wellness
Is this your first Professional Massage?*
No
Yes
Do you currently have, or have you had, any injuries or medical conditions in the last 2 years?*
No
Yes

If Yes, indicate details and date
Are you currently experiencing any muscular pain or discomfort?*
No
Yes

If Yes, please explain
Are you pregnant?*
No
Yes

If Yes, how far along?
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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