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SPA FOR MOTHER & DAUGHTER
SPA FOR MEN
SPA FOR TEENS
URBANA SPA PARTY
URBANA TEA PARTY
MICRODERMABRASION & PEELS
WAXING & TINTING
LOOSE LEAF TEAS
on all orders $40 and more
SERVICE FORM FOR SOUTH CHARLOTTE
Please complete the form below to help us serve you.
Step 1 of 5
Date of Birth
Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
How did you hear about us?
Referred by a Friend or Family member
Received a Gift Card
Searched on the Internet
Are you aware of any allergies you may have, including oils, lotions or nuts?
If yes, please list:
Are you pregnant?
If yes, when is your due date? (MASSAGE ONLY AFTER 1ST TRIMESTER)
Please list any physical activities you do on a regular basis:
If under a physician’s care within the past 12 months, for what reason(s)?
Please check off any of the following that have applied or apply to you currently:
High/low blood pressure
Please list and explain other conditions, symptoms or injuries you’ve had or have currently:
Please list any medications and/or supplements you are currently taking (including Accutane, Retina A, or Renova):
When was your last massage?
Your Appointment today is for:
Please describe your condition:
Please list any current pains you are experiencing (if any):
Do you prefer...
A light touch
A medium touch
A firm touch
Do you bruise easily?
Do you prefer talking during your massage?
When was your last facial?
Have you ever had any chemical peels, microdermabrasion, or any resurfacing treatments?
If yes, when was your last treatment?
Do you sunbathe or use tanning beds?
If yes, how often?
Are you using any products containing any of the following (check if yes):
Are you prone to cold sores?
What are your skin care goals?
I hereby give my consent to receive massage services and/or facials from Urbana Wellness Spa, and I acknowledge and agree that I am doing so at my own risk. My health and safety with respect to these services are my sole responsibility. My decision to receive services from Urbana Wellness Spa is voluntary, and I know of, understand, and assume any and all risks associated therewith. I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow. I also understand that massage is entirely therapeutic and non-sexual in nature. I affirm that I have notified my therapist of all known medical conditions and injuries. If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any discomfort I experience during or after the session. I agree to inform the therapist of any changes in my health and medical condition understanding that there will be no liability to the therapist if I fail to do so. I understand the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness. By signing this release, I, for myself and on behalf of my heirs, executors, administrators, and personal representatives, hereby waive, release, discharge, and hold harmless Urbana Wellness Spa, its members, owners, officers, agents, and employees for any and all liability for any and all injuries including death, damages, or claims relating to or in result of my services at Urbana Wellness Spa, now or in the future, foreseen or unforeseen. Further, I hold harmless Urbana Wellness Spa, its members, owners, officers, agents, and employees from or against any and all claims, rights, damages, liabilities, losses, costs, and expenses (including attorneys’ fees) arising from or in connection with any injuries to other persons or damage to property caused by or attributed to me. I acknowledge that I have received, read, and understand the waiver and agree to all the information within. By signing this form, you represent that you completed the above information to the best of your knowledge and will inform your therapist of any changes that occur.