Rediscover Your Source
Name:
Male
Female Date:
Street Address:
City:
State:
Zip:
Home phone:
Cell phone:
Date of Birth:
E-mail Address:
Emergency Contact Person:_______________________ Phone: ______________________________________
How did you hear about us?
________
May we add you to our e-mail list
Yes
No
1. Please check any of the following that apply:
Abdominal/Digestive
Constipation/Diarrhea
Allergies
Depression
Anxiety
Diabetes
Arthritis/Tendonitis
Fatigue
Asthma or Lung Cond.
Headaches, Migraine
Athletes Foot
Hearing Problems
Blood Clots
Hernia
Chronic Pain
High or Low Blood Pressure
Circulatory/Heart
Muscle/Bone Injuries
Please provide any additional information or list other concerns:
Muscle/Joint Pain
Numbness/Tingling
Rash/Fungus
Sinus Problems
Sleep Difficulties
Spinal Disorders
Sprain/Strain
Tension/Stress
Vision Problems
______
2. Are you currently taking any medications (prescribed as well as non-prescribed)?
please list:
3. Are you currently pregnant or undergoing fertility treatments?
Yes
Yes
No If yes,
No
4. Are you currently or have you recently used/taken:
Accutane
Retin-A, Renova, Kinerase
Tazorac
Antibiotics
Other:
5. I promise to update the technician regarding any changes since my last visit?
Yes
No
I understand and acknowledge there are risks involved with treatment of facials, massages, body, nail and hair care. I understand that any false or
misleading information I have given may lead to undesired results and complications and hereby waive Yuan Spa’s liability if such results or
complications occur. In consideration of Yuan Spa performing any procedure(s), I agree to assume the risk and full responsibility of any and all
injuries, losses or damages which might occur to me while I am undergoing any procedure or side effects I may experience after the procedure is
performed. Furthermore, I understand that the massage therapist, esthetician, body, nail and hair technicians do not diagnose illness, disease or any
other physical or mental conditions. Furthermore, any sexual misconduct exhibited by the Guest will result in immediate termination of the session,
and the guest will be liable for payment of the scheduled appointment. Finally, to the maximum extent allowed by law, I agree to waive and release
any and all present and future claims, suits or related causes of action against Yuan Spa.
Guest Signature:
Printed name:
Date:
Continue to second page

SPA CONSENT FORM
Reduce the Risk of Overheating and Scalding
1. Prolonged exposure to the Sauna, Steam Room or Bathing Pools may cause your body to overheat.
Limit yourself to a maximum of ten (10) minutes. Overexposure to high temperatures and humidity
can be dangerous to your health. Exit immediately if nauseous, uncomfortable, dizzy or sleepy.
2. Children under the age of 16 should not use this facility.
3. Check with a doctor before using if pregnant, diabetic, in poor health or under medical care.
4. Do not use this facility if you have recently consumed alcohol, drugs or medications.
5. Be aware that direct contact with Steam Head, Sauna Rocks or Salt Filter may cause serious injury.
6. Do not use Sauna, Steam Room or Bathing Pools after consumption of alcohol.
Reduce the Risk of Slipping and Falling
1. Use care when entering or exiting the Sauna, Steam Room or Bathing Pools.
2. Floors may be slippery and dangerous due to moisture. Use of proper footwear is recommended at all
times.
3. The Steam Room is equipped with an aromatic dispensing system using Eucalyptus Essential oils.
Leave the room immediately if you have any adverse or allergic reaction, including difficulty breathing
or eye, nasal or throat irritation.
_________________________________________________________________
Guest (Print)
____________________________________________
Date
_________________________________________________________________
Guest Signature
_________________________________________________________________
Spa Concierge Signature
____________________________________________
Date