Privacy of personal information is an important principle to Essentials South Tampa Day Spa. We are committed to collecting, using and disclosing personal information responsibly and only to the extent necessary for the goods and services we provide. 

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Essentials South Tampa Day Spa
4325 Henderson Blvd
Tampa, Fl 33629


Review Essentials South Tampa Day Spa Privacy Policy

PLEASE READ/INITIAL THAT YOU UNDERSTAND THE FOLLOWING POLICIES:

LATE ARRIVALS: We regret that late arrival for your appointment may deprive you of valuable treatment. 

 

CANCELLATION POLICY: Please be aware that we require 24-hour advanced notice for all appointment cancellations. Voicemail messaging is available 24 hours a day for your convenience. Missed appointments without proper notice may be subject to a $25 cancelation fee, and you will be required to either prepay for future appointments or put a credit card on file to charge future cancellation fees. If there is no card on file, the full amount of the missed service will be collected before another appointment can be scheduled. 

 

MEDICAL: For your protection, please inform us of any medical conditions or other special needs that may require our attention to make your visit a pleasant one. This includes skin care products that may interfere with facial and waxing services. In the event your health history changes, please notify us and complete a new Client Intake Form. 

 

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any discomfort during the session, I will immediately inform the practitioner, so the pressure may be adjusted to my level of comfort. I further understand that a Licensed Massage Therapist (LMT) can neither diagnose illness, disease or any other medical, physical, or mental disorder; nor perform any spinal manipulations. I am responsible for consulting a qualified physician for any ailment that I have. Because a LMT must be aware of any change in my physical health, I understand there shall be no liability on the practitioner’s part or Essentials Massage & Facials of South Tampa should I fail to do so. I also understand that any sexually suggestive remarks of advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

I hereby give my consent and authorization voluntarily and release Essentials of South Tampa from any claims, implied or stated that, I have or may have in the future with this treatment/service, regardless of result. I am stating that the treatment/service and precautions above have been explained to me in detail and that I fully understand.

First Client's Name

First Name*

Last Name*

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

First Name*

Last Name*

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

First Name*

Last Name*

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

First Name*

Last Name*

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

First Name*

Last Name*

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

First Name*

Last Name*

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

First Name*

Last Name*

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

First Name*

Last Name*

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

First Name*

Last Name*

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

First Name*

Last Name*

Phone*
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*

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

Emergency Contact's Name*

Emergency Contact's Phone Number*
General Health
How would you describe your stress level?*
Low
Medium
High
Very High
Do you smoke?*
No
Yes
Do you drink?*
No
Yes
Do you wear contacts or glasses?*
No
Yes
Do you exercise regularly?*
No
Yes
Do you have any of the following? *
Metal implants
A Pacemaker
Body piercings
None of the above
Are you pregnant?*
No
Yes

List any major injuries, accidents, or surgeries

List any medications you are taking
Brief health history (Check all that apply)
Allergies to fragrance
Allergies
Anxiety
Arthritis
Asthma
Blood clots
Broken/ Fractured bones
Bruise easily
Cancer
Chronic Pain
Depression
Diabetes
Disk problems
Fatigue/ Sleep disorder
Flu/ Cold symptoms in last 48 hours
Fybromyalgia
Gas/Bloating
Headaches
Heart Condition
Herpes
High/Low blood pressure
Infectious Disease
Lymphedema
Numbness/ Tingling
Osteoporosis
Poor circulation
Rashes
Sciatica
Scoliosis
Seizures/ Epilepsy
Shingles
Sinus problems
Spasms/ Cramps
Sprains/ Strains
Stroke
Thyroid Dysfunction
TMJ
Varicose veins
Have you had a professional massage before?*
No
Yes
Reasons for massage therapy
Relaxation
Stress Reduction
Pain Relief
What type of pressure do you prefer?*
Light
Medium
Deep
Are you currently under the care of a dermatologist?*
No
Yes
Have you used any of the following?
Accutane
Retin-A
Renova
Adapalene Hydroxyl Acid
Have you had any of the following?
Chemical Peels
Microdermabrasion
Botox/ Fillers
Laser
Microneedling
Dermaplaning
Cold Sores
Allergies to Aspirin
Taken Accutane in the last year
Do you have any skin sensitivities or irritants?*
No
Yes

List your skin concerns if any.
Have you been diagnosed with any of the following?
Eczema
Psoriasis
Vitiligo
Other
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*

Phone*
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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