Spa Intake Form

Full name*

Date of birth*

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are you pregnant?*

Yes
No

Please indicate how many weeks along you are*

Do any of the following apply to you currently*

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Please list them*

List any activities, sports or hobbies

Any known allergies?*

Yes
No

Please list any allergies you have

Are you taking any medications right now?*

Yes
No

Please list any medications you are taking*

List any accidents or surgeries in the last 12 months

Are there any concerns which you would like your service provider to focus on or pay particular attention to

How did you hear about us?*

Google
Instagram
Facebook
Newspaper Ad
Friend
Family Member
Other

Please specify*

Contact Preferences

I 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*

Signature*

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Contact Preferences

Please Read Carefully

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