Loading...

Guest Consultation For Bodywork

Consent for Treatment

If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes 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 therapists are not qualified to perform spinal or skeletal adjustments, diagnosis, 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 and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and I understand that there shall be no liability on Majesty Day Spa or the therapist part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for full payment of the scheduled appointment.. Understanding all of this, I give my consent to receive treatment.

Dated: August 19, 2022

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

List the medications you currently take:
Are you currently wearing any of the following items? Check all that apply YES.
Hairpiece
Dentures
Contacts
Are you pregnant?*
No
Yes

Health History


Have you had any injuries or surgeries in the past that may influence today's treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask):
Blood clots
Infections
Congestive heart failure
Contagious diseases
Pitted edema

Please answer honestly, as massage may not be indicated for the above conditions.

First Client's Signature*
Second Client's Name

First Name*

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

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

List the medications you currently take:
Are you currently wearing any of the following items? Check all that apply YES.
Hairpiece
Dentures
Contacts
Are you pregnant?*
No
Yes

Health History


Have you had any injuries or surgeries in the past that may influence today's treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask):
Blood clots
Infections
Congestive heart failure
Contagious diseases
Pitted edema

Please answer honestly, as massage may not be indicated for the above conditions.

Third Client's Name

First Name*

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

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

List the medications you currently take:
Are you currently wearing any of the following items? Check all that apply YES.
Hairpiece
Dentures
Contacts
Are you pregnant?*
No
Yes

Health History


Have you had any injuries or surgeries in the past that may influence today's treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask):
Blood clots
Infections
Congestive heart failure
Contagious diseases
Pitted edema

Please answer honestly, as massage may not be indicated for the above conditions.

Fourth Client's Name

First Name*

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

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

List the medications you currently take:
Are you currently wearing any of the following items? Check all that apply YES.
Hairpiece
Dentures
Contacts
Are you pregnant?*
No
Yes

Health History


Have you had any injuries or surgeries in the past that may influence today's treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask):
Blood clots
Infections
Congestive heart failure
Contagious diseases
Pitted edema

Please answer honestly, as massage may not be indicated for the above conditions.

Fifth Client's Name

First Name*

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

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

List the medications you currently take:
Are you currently wearing any of the following items? Check all that apply YES.
Hairpiece
Dentures
Contacts
Are you pregnant?*
No
Yes

Health History


Have you had any injuries or surgeries in the past that may influence today's treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask):
Blood clots
Infections
Congestive heart failure
Contagious diseases
Pitted edema

Please answer honestly, as massage may not be indicated for the above conditions.

Sixth Client's Name

First Name*

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

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

List the medications you currently take:
Are you currently wearing any of the following items? Check all that apply YES.
Hairpiece
Dentures
Contacts
Are you pregnant?*
No
Yes

Health History


Have you had any injuries or surgeries in the past that may influence today's treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask):
Blood clots
Infections
Congestive heart failure
Contagious diseases
Pitted edema

Please answer honestly, as massage may not be indicated for the above conditions.

Seventh Client's Name

First Name*

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

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

List the medications you currently take:
Are you currently wearing any of the following items? Check all that apply YES.
Hairpiece
Dentures
Contacts
Are you pregnant?*
No
Yes

Health History


Have you had any injuries or surgeries in the past that may influence today's treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask):
Blood clots
Infections
Congestive heart failure
Contagious diseases
Pitted edema

Please answer honestly, as massage may not be indicated for the above conditions.

Eighth Client's Name

First Name*

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

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

List the medications you currently take:
Are you currently wearing any of the following items? Check all that apply YES.
Hairpiece
Dentures
Contacts
Are you pregnant?*
No
Yes

Health History


Have you had any injuries or surgeries in the past that may influence today's treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask):
Blood clots
Infections
Congestive heart failure
Contagious diseases
Pitted edema

Please answer honestly, as massage may not be indicated for the above conditions.

Ninth Client's Name

First Name*

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

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

List the medications you currently take:
Are you currently wearing any of the following items? Check all that apply YES.
Hairpiece
Dentures
Contacts
Are you pregnant?*
No
Yes

Health History


Have you had any injuries or surgeries in the past that may influence today's treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask):
Blood clots
Infections
Congestive heart failure
Contagious diseases
Pitted edema

Please answer honestly, as massage may not be indicated for the above conditions.

Tenth Client's Name

First Name*

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

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

List the medications you currently take:
Are you currently wearing any of the following items? Check all that apply YES.
Hairpiece
Dentures
Contacts
Are you pregnant?*
No
Yes

Health History


Have you had any injuries or surgeries in the past that may influence today's treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask):
Blood clots
Infections
Congestive heart failure
Contagious diseases
Pitted edema

Please answer honestly, as massage may not be indicated for the above conditions.

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*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
How did you hear about us?

How did you hear about us: *
Massage Enhancements
Please choose from our list of add-ons that aim to enhance your massage experience.
TABLE WARMER...Enjoy complimentary heated therapy by choosing this option to have your table warmer turned on during your massage...FREE
AROMATHERAPY...This massage uses the restorative properties of 100% natural essential oils and coconut oil to relax and heal your body and mind...$10
HOT STONES...This heated therapy melts away tension, eases muscle stiffness and increases circulation. Heated stones allow your therapist to access deeper muscle layers for a enhanced massage...$15
HAND/FOOT SCRUB...Our organic sugar scrub will nourish & gentle exfoliate any dead dry skin then is removed with calming warm towels. Your hands and feet will emerge feeling baby soft...$18
SHOWER TIME...Majesty uses high quality organic creams & oils for massage that we recommend you leave on your skin for optimal hydration & benefit. However, we offer the option to book additional time for a steam shower...$15 per 10 min (subject to availability)
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*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

List the medications you currently take:
Are you currently wearing any of the following items? Check all that apply YES.
Hairpiece
Dentures
Contacts
Are you pregnant?*
No
Yes

Health History


Have you had any injuries or surgeries in the past that may influence today's treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask):
Blood clots
Infections
Congestive heart failure
Contagious diseases
Pitted edema

Please answer honestly, as massage may not be indicated for the above conditions.

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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!