Spa Intake Form Please take a moment to fill out our Spa Intake Form. We assure you that all information is kept confidential and will never be sold to a third party. Full name*Date of birth* Date Format: MM slash DD slash YYYY Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Are you pregnant?* Yes No Please indicate how many weeks along you are*Do any of the following apply to you currently*You can select multiple items by holding CTRL on Windows or CMD on Mac and selecting the optionsAsthmaAthletes FootCancerClaustrophobiaDiabetesEczemaPsoriasisEpilepsyHeart ConditionHepatitisHIV/AIDSHigh Blood PressureLow Blood PressureNail FungusPhlebitisSkin SensitivitySteel Pins/PlatesHypo ThyroidHyper ThyroidVaricose VeinsWartsOtherN/APlease list them*List any activities, sports or hobbiesAny known allergies?* Yes No Please list any allergies you haveAre you taking any medications right now?* Yes No Please list any medications you are taking*List any accidents or surgeries in the last 12 monthsAre there any concerns which you would like your service provider to focus on or pay particular attention toHow did you hear about us?* Google Instagram Facebook Newspaper Ad Friend Family Member Other Please specify* Contact PreferencesI consent to Melt Mineral Spa contacting me by email for appointment confirmation and specials* Yes No I consent to La Creme de la Creme contacting me by email for promotions & specials*La Creme de la Creme is our retail boutique for sleepwear, skincare & education. Yes No Please Read Carefully I acknowledge and understand that a person can unintentionally spread COVID‐19 to others even if they do not feel sick or have symptoms. I acknowledge and understand that my service provider, the staff, this business, or the owner of this business cannot completely control the spread of COVID‐19 and I have chosen to enter this business and consent to receive close contact service(s) with full knowledge of the risk of contracting COVID‐19 when social distancing is not observed. I acknowledge and understand that I should not attend my spa appointment if I am experiencing any symptoms of COVID-19. Because we are all in this together, all employees of Melt Mineral Spa also acknowledge and agree to these same standards and statements every day. By ticking the box below, I agree not to hold my service provider, the staff, this business, or the owner of this business liable for any exposure to COVID‐19 while at Melt Mineral Spa.I acknowledge and agree to the following:* Yes I acknowledge and understand that the use of cell phones in Melt Mineral Spa is prohibited. I acknowledge and understand that there are risks associated with services provided by Melt Mineral Spa. I acknowledge that my participation in these treatments is entirely voluntary. I agree to discuss my concerns about possible risks with my service provider before the treatment and immediately advise them if I become uncomfortable in any way during my treatment. I acknowledge and understand that it is important for the service provider to know my relevant medical history and that I have disclosed all known medical conditions, including any mental or emotional conditions for which I have received treatment within the last 12 months. I will disclose any new condition that may develop after my completion of this form. The information disclosed by me is true and complete to the best of my knowledge. I authorize copies of any patient record created at Melt Mineral Spa to be shared with all registered professionals who work at Melt Mineral Spa who may provide me with treatment. I acknowledge inappropriate conduct of any nature will not be tolerated and may result in the treatment being terminated. I assume all risks involved in my participation in the services provided by Melt Mineral Spa, its employees and spa service providers. I agree to release and forever discharge Melt Mineral Spa, its owners, its directors, employees and contractors from any claims, losses, damages, actions or causes of action arising out of any loss, injury, damage to my person or property arising from my involvement with the services provided by Melt Mineral Spa. The contents of this form and my patient records will be kept confidential unless I have expressly or impliedly consented to the release of my information. I acknowledge and confirm that no guarantee or assurance of treatment results have been made to me regarding my services provided by Melt Mineral Spa. I acknowledge that I am over the age of 18, have read this Waiver, understand it and I agree to be bound by this Release and Indemnity. *if I do not understand and therefore am not capable of providing consent, or under the age of 18, this consent is instead provided by an individual who is authorized and able to make health care decisions on my behalf (parent or legal guardian).I acknowledge and agree to the following:* Yes Date signed* Date Format: MM slash DD slash YYYY Signature* First Last EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.