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We want you to have an enjoyable and safe experience with us at Rejuvenate. We ask that you be aware of and agree to the following information and policies:

By signing this waiver, you agree to the following regarding our various services:

We have included everything on one waiver so that you will not need to fill out additional forms with future visits.

 

MASSAGE AND BODY SERVICES

Including: massage therapy and Thai massage of any modality, FAKTR, kinesiology taping, reflexology, energywork, Crystal healing, Cupping therapy, scrubs and body wraps, paraffin, and any other service we may add in the future that is performed by the licensed massage therapists or certified crystal/energy healing practitioners at Rejuvenate. 

I understand that I need to advise the therapist if the pressure is too much or too little, or if I am experiencing any pain or discomfort.

I am aware that the massage and body services are provided by licensed professionals and any attempt to sexualize my massage will result in termination of the service. If this happens, I understand that I will be charged for 100% of the scheduled service cost.

I am aware that drinking plenty of water after a massage is said to help eliminate toxins from my body and that failure to do so (especially after a deep tissue massage) may cause me to feel ill or naseaus. 

I am able to safely recieve massage and body services with my current state of health. If I have any concerns that my health could be adversly affected by the services I have scheduled, I agree to discuss with my doctor prior to receiving the service. 

>> I have read and agree to all of the above regarding my massage, energywork, and any add-on body services  

I Agree

 

SAUNA

I understand that the sauna can reach 140 degrees farenheight and that any of the below contraindications will require me to use discretion for my own wellbeing. I acknowledge that severe medical conditions or pregnancy will require a note of authorization from my doctor prior to the use of the infrared sauna:

Medications: Diuretics, barbituates, and beta-blockers may impair the body's natural heat loss mechanisms. Anticholinergics such as amitryptaline may inhibit sweating and can predispose individuals to heat rash or, to a lesser extent, heat stroke. Some over the counter drugs, such as antihistamines, may also cause the body to be more prone to heat stroke. 

Pregnancy/breast feeding: Pregnant women should consult a physician and get written consent before using the infrared sauna. If breastfeeding, do not use the sauna. The detoxification process can expell toxins into your breast milk.

Mentruation: Heating of the low back area during you mentrual period may temporatily increase mentrual flow.

Elderly: The body must be able to activate its natural cooling processes in order to maintain a core body temperature. As we mature, our bodies naturally lose this capability. Guests over the age of 70 will be permitted for infrared sauna use, but at a lower temperature. 

Cardiovascular conditions: Individuals with cardiovascular conditions or problems (hypertension/hypotension), congestive heart failure, impaired coronary circulation, or those who are taking medications which might affect blood pressure should exercise caution when exposed to prolonged heat. Heat stress increases cardiac output and blood flow in an effort to transfer internal body heat to the outside environment via the skin (perspiration) and respiratory system. This takes place primarily due to major changes in the heart rate, which has the potential to increase by 30 beats per minute for each degree increase in core body temperature. 

Alcohol/Alcohol abuse: It is not advisable to "sweat out" a hangover. Alcohol intoxication decreases a person's judgement and they may not recognize a negative reaction to high heat. Alcohol also increases the heart rate, which may be further increased by heat stress. Guests who appear intoxicated or inform us of alcohol consumption prior to use of the sauna will forfeit their scheduled appointment and no refund or credit will be issued

Chronic conditions/diseases associated with reduced ability to perspire: Multiple sclerosis, central nervous system tumors, and diabetes with neuropathy are conditions that are associated with impared sweating and we recommend speaking with a doctor before using the sauna.

Hempphiliacs/individuals prone to bleeding: Do not use the sauna

Fever: We recommend avoiding the use of a sauna until your fever subsides.

Join Injury: If you have a recent (acute) joint injury, it should not be heated for the first 48 hours of injuring or until swollen symptons subside. If you have joints that are chronically hot and swollen, they may respond poorly to vigorous heating of any kind.

Implants: metal pins, rods, artificial joints, or any other surgical implants generally reflect infrared waves and thus will not be heated by this sauna system. Nevertheless, you should consult your physician prior to using an infrared sauna.

Pacemakers/defibrillators: the magnets used to assemble infrared saunas can interrupt the pacing and inhibit the output of pacemakers. Please discuss with your doctor the possible risks this may cause.

>> I have read and understand the above contrainidcations. I understand that if I use the sauna and experience any pain or discomfort, that I will immediately discontinue sauna use and exit the sauna.

I Agree

 

SALT FLOAT SESSIONS

I agree to NOT use the float pod under any of the following circumstances:

- if I have not showered throroughly with the provided "pre-float" body wash provided by Rejuvenate to removed any creams, oils, or makeup 

- if I have had any type of hair color/treatment within the past two weeks or have any hair color that would bleed into the water or onto a white towel 

- if I am under the influence of drugs or alcohol

- if I have a communicable or infectious skin condition, disorder, or disease

- if I have open sores

- if I am diabetic, unless my diabetes is under medical control

- if I have a history of heart trouble, epilepsy, seizures, or blackouts, and have not received my doctors (written) permission to use the float pod

- if I am menstruating or experiencing some other sort of external vaginal episode

- if I have a condition which may be adversely affected by cutaneous absorption of magnesium

- if I have kidney disease and have not received my doctor's (written) permission to use the float pod

- if I may release bodily fluids, voluntarily or involuntarily, into the float pod

Please note: Our staff is not trained in assisted transfers. If you need assistance getting in or out of the float pod, it is best for your to bring your own helper.

>> I have read and understand all of the terms listed above. I understand that violation of any of these rules that result in contamination of the float pod water may result in a cleaning and salt replacement fee of up to $1000

I Agree

 

 

 

CLASSES:

This includes and yoga, fitness, dance, and meditation classes, as well as any other classes or workshops of any sort that we may provide now or in the future.

I will make sure that I am physically and mentally able to participate in any classes at Rejuvenate before attending and to consult with my physician before beginning any new exercise . I understand that some of the classes are phsyically strenuous and that I will discontinue the activity should I experience any pain.

I understand that Rejuvenate and its instructors are in no way responsible for the safekeeping of my personal belongings while I attend class.

>> I have read and agree to all of the above statements about classes

I Agree

 

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FACILITIES: Amenities provided include (depending on service): towel, washcloth, ear plugs, shampoo/body wash, and shower. It is up to each individual to take caution to prevent slipping or falling as floor surfaces may be wet. Also, the water can get very hot, please use caution when showering. The float room and sauna are cleaned and massage sheets changed between each session. The float pod solution is sanitized and filtered to meet or exceed the standards of the Flotation Tank Association. 

FEES: Fees may vary based on the desired service package. These fees are subject to change. We require payment for services at the time of service (or, if deemed necessary, at the time of booking as mentioned in our cancellation policy below)

CANCELLATION POLICY: We require 24 hour notice for any cancellations for a full refund/no charge. No-shows or cancellations made with less than 24 hour notice will be charged for 50% of the scheduled service cost except under extreme circumstances. If this becomes a habit, we reserve the right to require payment at the time of booking your appointment.

PRIVACY POLICY: All information provided on this form is stored securely and only accessible by Rejuvenate practitioners 

 

RELEASE OF LIABILITY: 

I consent to all services that I recieve today and in the future. I understand that none of the services or classes offered at Rejuvenate are a substitution for medical treatment and that no medical diagnosis or treatment is made or inferred. I agree to keep the practitioner(s) updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so. 

In signing this waiver, I hereby absolve, waive, release and agree to indemnify and defend Rejuvenate Massage Therapy and its agents (ie. pracitioners/insructors/staff/independant contractors) from and against any and all liability or claims in connection with any products, classes, or services, regardless of the nature of such claimed loss or damages, direct or indirect. This agreement of waiver of liability and all agreements made herein shall apply to each time I use the products and services of Rejuvenate Massage Therapy. 

November 20, 2018

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Health History
Have you had a massage before?*
No
Yes
What is your preference in pressure?*
Light
Moderate
Deep
Have you experienced a salt float before?*
No
Yes

Please list any recent surgeries, medical problems, or pre-existing conditions diagnosed by your doctors:

Please list any allergies:

Please list any drugs/medications you are currently taking and their purpose:
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Health History
Have you had a massage before?*
No
Yes
What is your preference in pressure?*
Light
Moderate
Deep
Have you experienced a salt float before?*
No
Yes

Please list any recent surgeries, medical problems, or pre-existing conditions diagnosed by your doctors:

Please list any allergies:

Please list any drugs/medications you are currently taking and their purpose:
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Health History
Have you had a massage before?*
No
Yes
What is your preference in pressure?*
Light
Moderate
Deep
Have you experienced a salt float before?*
No
Yes

Please list any recent surgeries, medical problems, or pre-existing conditions diagnosed by your doctors:

Please list any allergies:

Please list any drugs/medications you are currently taking and their purpose:
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Health History
Have you had a massage before?*
No
Yes
What is your preference in pressure?*
Light
Moderate
Deep
Have you experienced a salt float before?*
No
Yes

Please list any recent surgeries, medical problems, or pre-existing conditions diagnosed by your doctors:

Please list any allergies:

Please list any drugs/medications you are currently taking and their purpose:
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Health History
Have you had a massage before?*
No
Yes
What is your preference in pressure?*
Light
Moderate
Deep
Have you experienced a salt float before?*
No
Yes

Please list any recent surgeries, medical problems, or pre-existing conditions diagnosed by your doctors:

Please list any allergies:

Please list any drugs/medications you are currently taking and their purpose:
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Health History
Have you had a massage before?*
No
Yes
What is your preference in pressure?*
Light
Moderate
Deep
Have you experienced a salt float before?*
No
Yes

Please list any recent surgeries, medical problems, or pre-existing conditions diagnosed by your doctors:

Please list any allergies:

Please list any drugs/medications you are currently taking and their purpose:
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Health History
Have you had a massage before?*
No
Yes
What is your preference in pressure?*
Light
Moderate
Deep
Have you experienced a salt float before?*
No
Yes

Please list any recent surgeries, medical problems, or pre-existing conditions diagnosed by your doctors:

Please list any allergies:

Please list any drugs/medications you are currently taking and their purpose:
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Health History
Have you had a massage before?*
No
Yes
What is your preference in pressure?*
Light
Moderate
Deep
Have you experienced a salt float before?*
No
Yes

Please list any recent surgeries, medical problems, or pre-existing conditions diagnosed by your doctors:

Please list any allergies:

Please list any drugs/medications you are currently taking and their purpose:
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Health History
Have you had a massage before?*
No
Yes
What is your preference in pressure?*
Light
Moderate
Deep
Have you experienced a salt float before?*
No
Yes

Please list any recent surgeries, medical problems, or pre-existing conditions diagnosed by your doctors:

Please list any allergies:

Please list any drugs/medications you are currently taking and their purpose:
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Health History
Have you had a massage before?*
No
Yes
What is your preference in pressure?*
Light
Moderate
Deep
Have you experienced a salt float before?*
No
Yes

Please list any recent surgeries, medical problems, or pre-existing conditions diagnosed by your doctors:

Please list any allergies:

Please list any drugs/medications you are currently taking and their purpose:
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information and discounts by e-mail (once a month or less)
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.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Health History
Have you had a massage before?*
No
Yes
What is your preference in pressure?*
Light
Moderate
Deep
Have you experienced a salt float before?*
No
Yes

Please list any recent surgeries, medical problems, or pre-existing conditions diagnosed by your doctors:

Please list any allergies:

Please list any drugs/medications you are currently taking and their purpose:
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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