Relaxation Package Release Form
Please complete this form to provide your information, health disclosures, and consent before receiving your relaxation package.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Appointment Date and Time
*
Do you have any allergies? If yes, please list them.
Are you currently taking any medications? If yes, please specify.
Do you have any of the following conditions? (Check all that apply)
Heart condition
High blood pressure
Diabetes
Skin conditions
Recent surgery
Pregnancy
None of the above
Other (please specify)
Please indicate any preferences or special requests for your relaxation session.
Signature (Please sign below to confirm your consent and release)
*
Submit
Submit
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