Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Phone *

(###)

###

####

Do you have any allergies to oils, lotions, or ointments? *

Yes

No

Are you currently under medical supervision? *

Yes

No

Are you currently taking any medication? *

Yes

No

Consent for Treatment *

I understand that massage and spa services received is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during a massage session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I understand that all massage and spa services at this facility are therapeutic in nature. Results will vary between individuals; as the possibility and nature of complications cannot be accurately anticipated, there can be no guarantee, either expressed or implied, to the success or other result of treatment. Should I choose to experience Fire Cupping therapy in my treatment, now or in the future, I understand the therapist will discuss the procedure, effects, contraindications, and after-care recommendations at that time. I acknowledge that I will have the opportunity to ask any questions about the treatment, including risks or alternatives, until all questions about the procedure are answered in a satisfactory manner prior to commencing Fire Cupping therapy. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment, and that I should seek a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment that I am aware of. Because massage should not be performed under certain medical conditions, I affirm that I have stated all relevant physical and medical conditions, and answered all questions honestly. I agree to inform the therapist to any changes in my medical profile and understand that there shall be no liability on the part of the therapist or Sugar Magnolia Spa should I fail to do so. To maintain the safety of our therapists, patrons, and other staff members, Sugar Magnolia Massage & Spa reserves the right to refuse service to individuals who are showing outward signs of illness, intoxication or recreational drug use, or make derogatory or bigoted comments, or sexual or romantic advances. Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session.

I have fully read and understand this agreement.