Rejuvenation Spa

Welcome! In order to make your experience as pleasant and comfortable as possible, we ask for you to fill out our on-line new client form before your visit to Rejuvenation Spa. If you prefer to download a printable version of the form, please click on the following link:
Printable new guest form (PDF).

If, at any time, you have questions regarding your visit, please let us know.

First Name: *
Last Name: *
Address: *
City: *
State: *
ZIP: *
Telephone: *	(ex: 123-456-7890)
Email: *
Date of Birth: *	(ex: MM/DD/YYYY)
Sex: *	male	female
Occupation:
Referred By:
Would you like to receive last minute email offers? *	yes	no

Have you received a professional massage before? *	yes	no
If yes, how often?
What was the favorite part of your last massage?
Do you have any difficulty lying on your front, back, or side? *	yes	no
If yes, please explain:
Do you have any allergies? *	yes	no
If yes, please describe:
Are you currently taking any medications? *	yes	no
If yes, please list:
Are you currently under the care of a medical professional? *	yes	no
If yes, please explain:
Do you sit for long hours at a desk, computer, or while driving? *	yes	no
If yes, please describe:
Do you perform any repetitive movement in work, sport, or hobby? *	yes	no
If yes, please describe:
Are you pregnant? *	yes	no
If yes, please state week of pregnancy:
Are you experiencing specific tension, stiffness, or pain? *	yes	no
If yes, please identify:
Do you have any particular goals for this massage session? *	yes	no
If yes, please identify:

Please check all conditions that apply: headaches/migraines contagious skin condition plantar warts open sores or wounds easy bruising recent accident or injury recent fracture recent surgery sprains/strains current fever heart condition high or low blood pressure circulatory disorder varicose veins atherosclerosis deep vein thrombosis/blood clots joint disorder diabetes Fibromyalgia TMJ carpal tunnel syndrome tennis elbow Accutaine, Differin or Retin A Other:

Informed Consent I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this 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 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 that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage 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 understand that there shall be no liability on Rejuvenation Spa or the therapist's part should I fail to do so. Parent or guardian must give consent for guests 17 and under.