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Brunch Services (girls night in)
Name
Home Address
Emergency Contact Name/Number
Birth date?
Allergies?(OPTIONAL)
Oils
Lotions
Allergies?(OPTIONAL)
Yes
No
If so, how many weeks?(OPTIONAL)
Currently under medical supervision? If so, why?
If necessary, I have clearance from my physician to receive massage therapy services, and any other services that will be rendered by Pamper Us Mobile Massage Service
Yes
No
Please list any known medical conditions.(OPTIONAL)
It is my choice, as a client, to receive massage therapy services from Pamper Us Mobile Massage Service and its affiliates. I understand that bodywork and massage therapy given here is for the purpose of stress reduction, relief from muscular tension or spasm, for increasing circulation and energy flow. If I experience any pain or discomfort during this session, I will immediately inform the massage therapist so that pressure or strokes may be adjusted to my level of comfort.
Yes
No
I understand that massage therapists do not diagnose illness, disease or any other physical or mental disorder; nor do they prescribe medical treatment of any kind. I acknowledge that massage is not a substitute for medical examination, diagnosis or treatment, and that it is recommended that I see a physician for these services.
Yes
No
I understand that all oil's and lotions used are hypoallergenic and non-scented. I understand that Pamper Us is not responsible for any allergic reactions.
Yes
No
Pamper Us is not responsible for any discrepancies associated with the massage therapist, nail technician, make up artist and their services. I understand that that they are independent contractors and have no legal affiliation with Pamper Us.
Yes
No
Pamper Us and the independent contractors are not responsible for any injuries that may occur during mobile services. Client that booked services is taking full responsibility of themselves and their guests during the times that the services are rendered.
Yes
No
Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and have answered all questions honestly. I agree to take it upon myself to keep the massage therapist updated on my health and wellbeing and I understand that there shall be no liability on the practitioner‘s part should I fail to do so.
Yes
No
I HAVE REVIEWED THE UNSERVICEABLE CONDITIONS LINK AT THE BOTTOM OF THE WEBSITE AND I DO NOT HAVE ANY OF THE CONDITIONS DISPLAYED ON THE UNSERVICABLE CONDITIONS LIST.
Yes
No
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