Client Intake Form The Spa at Windsor Court Client Intake Form Please complete this form prior to obtaining treatments. Thank you. To book an appointment please email us at firstname.lastname@example.org. Once we have booked your appointment with us, please complete this form before your spa service arrival time. Thank you.Client SectionName Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email PhoneAll guests are required to wear a mask throughout their time in the Spa facilities as well as during their massage, body treatment, or manicure/pedicure service.* I have read and agree to the treatment statement above. General MedicalHave you had fever, cough, shortness of breath or other symptoms consistent with COVID-19 within the past 72 hours?* YES NO Have you been in contact with any individual with fever or symptoms consistent with COVID-19 within the past 14 days?* YES NO Do you have any allergies?* YES NO Are you pregnant? If yes, how many months?* YES NO Months Pregnant (if applicable)Do you have diabetes?* YES NO Do you have a medical condition or injury that your therapist should be aware of?* YES NO Are you currently taking any medication or under any medical treatment?* YES NO EstheticsAre you currently taking Accutane or using Retin-A?* YES NO Do you have a history of seizures or epilepsy?* YES NO Are you wearing contact lenses?* YES NO Implanted Medical Device?* YES NO In the last 72-hours have you used? alpha-hydroxy / glycolic/resorcinol / scrub / peel / microderm* YES NO Do you have or are you prone to? ingrown hairs / bumps / hyper-pigmentation / bruising* YES NO Manicure PedicureDo you have any injuries on hands/feet/ingrown nails?* YES NO Have you recently shaved or waxed your arms/legs?* YES NO Are you using sunless tanning application or tanning beds?* YES NO Do you have any injuries we should be aware of?* YES NO Note InjuriesAuthorizationPlease, take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, your treatment may be contraindicated.I understand that treatments I receive are 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 practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment, and that I should see a physician, or other qualified medical specialist for any ailment that I am aware of. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental conditions. I affirm that I have stated all my known medical conditions, and answered all the questions honestly. I agree to keep the practitioner updated of any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in the immediate termination of the session, and I will be liable for payment of the scheduled appointment. We reserve the right to refuse service. Enter your email address below and check the CONSENT box to authorize treatment.*Consent* I have read and agree to the treatment statement above.PhoneThis field is for validation purposes and should be left unchanged.