Intake Form

    Welcome to Mandara Spa!

    Dear Guest, the Mandara Spa intake form is a very important component of your overall spa experience. Please complete the form to the best of your knowledge and state all health & medical conditions so that we can make recommendations or adjust treatments accordingly, rest assured your confidential information will be kept in secure files and will only be used by Mandara Spa

    If you would like to receive appointment notifications, or monthly specials please provide your email address below. (Rest assured you will not receive junk mail or newsletters)
    YesNo

    General Information

    How did you hear about us?

    Have you visited our website? (mandaraspa.ca) YesNo

    General Health

    Overall, how is your general health?Very GoodGoodFairPoorVery Poor

    Rate your level of stress (10 = highest, 1= lowest) 10987654321

    Are you diabetic? YesNo

    Do you wear contact lenses? YesNo

    Skin Care

    Skin TypeOily/CongestedDry/DehydratedSensitive/RednessSunburned Acne (minor/severe)EczemaClaustrophobia Iodine or Shellfish Psoriasis

    Face care products you currently use:SoapCleanserTonerMoisturizerExfoliatorMasque

    What are your skincare goals?PreventionMaintenanceRepairOther

    Massage Therapy

    What is your goal for your massage session?RelaxationPain ReliefStress Reduction

    *Please let the therapist know of any injuries, bruises or cuts prior to the treatment.

    Health History

    Heart ConditionHigh Blood PressureLow Blood PressureArthritis/Chronic PainBroken/Fractured BonesThyroid Condition (Hypo)Thyroid Condition (Hyper)AllergiesDiabetesHeadaches/MigrainesCancerClaustrophobiaJaw Pain/TMJSprains/StrainsInfectious condition (TB, HIV, Hepatitis)Spasms/CrampsFatigue/Sleep DisorderLymphedemaHerpes/ShinglesNumbness/TinglingRashesBlood Clots

    Please list any accidents or surgeries in the last 9 months:

    Date

    Date

    Date

    Please list any medications/supplements you are currently taking:

    Consent for Treatment

    Mandara Spa offers a variety of treatments including Massage, Facials, Body Treatments, Threading, Waxing, Manicures, Pedicures, Permanent Makeup, Tinting, Acupuncture, Peeling and Microdermabrasion Treatments. Our intention is to facilitate you through a healing process which includes physical, emotional, mental and spiritual levels. We believe that a balanced state on all of these levels leads to your health and well-being.

    Our staff consists of licensed massage therapists and full specialist technicians with a broad scope of certifications. Staff members are available to be your facilitators but you are always in charge of yourself and your session. Communication is the key to getting the treatment you want. We ask that you give verbal feedback to your practitioner throughout your session. If you are uncomfortable let your practitioner know immediately. If you have questions about your treatment please ask your practitioner for clarification. Your health needs and comforts will always be honored.

    We are not physicians and therefore do not diagnose or prescribe medications. Our staff will never advise you to discontinue any medical treatment you may be receiving. Our work is intended to be harmonious with other health practices, including allopathic medicine. Please feel free to discuss your treatments here at Mandara Spa with your doctor.

    Hydration is essential after all treatments. The release of tension from your muscle tissue releases toxins that must be eliminated from your body. Make sure to drink plenty of water after a treatment and throughout your day to help flush out these toxins so that they are not reabsorbed by your system. Soaking in a warm tub with Epsom salts the evening of your treatment is also a wonderful remedy. Most importantly, listen to your body as it communicates what it needs and honor yourself by meeting those needs. If you have any questions at this time please ask us for assistance. In signing the attached Acknowledgment and Release, you state full understanding of the information stated on this form.

    Acknowledgement & Release

    I hereby acknowledge that I have read the foregoing Consent for Treatment, am satisfied that I fully understand the nature of the spa services/treatments, and freely elect to receive these services today and in the future. I release Mandara Spa from any and all claims of malpractice, non-disclosure, or lack of informed consent. I freely assume any and all risks of the treatment whether presently contemplated or hereinafter discovered. I hereby consent to being subject to known risk, assume such risk, and therefore waive all rights in this respect and agree to protect, indemnify and hold harmless Mandara Spa and its agents from and against all losses, damages, demands, claims, suits, or other liabilities.

    I acknowledge my massage session may involve the use of oils, lotions, and possibly hot and/or cold items necessitating the need for me to remove most of my clothing. During this time, I understand I will be draped appropriately with linens for warmth and privacy. Only the specific area being treated will be undraped. If a session necessitates removal of clothing, and I would prefer to remain clothed, I WILL INFORM MY PRACTITIONER.

    I understand that the Spa services and massage treatments given by Mandara Spa practitioners are for relaxation, stress-reduction, relief from muscle pain or spasm, and/or for increasing circulation.

    I further understand that Mandara Spa practitioners do not diagnose illnesses or prescribe medical or pharmaceutical treatment. It has been made clear to me that massage is not a substitute for a medical examination and it is recommended that I contact a licensed health care provider for any medical or health condition.

    I also understand that as a result of some treatments, bruising, redness, cuts or flu-like symptoms may result. It is my choice to receive treatments and I have provided accurate information concerning all past and current health conditions. I agree to report any changes in my health as they arise.

    I understand my service or treatment may be terminated at the discretion of the Mandara Spa staff or management, on the grounds of any inappropriate behaviour or conduct (verbal or physical), or any inappropriate or foul body odor or skin problem, and no refund will be granted for such a termination.

    I understand that I am financially responsible for payment, upon service rendered. I acknowledge that If I do not show up for a scheduled appointment, I will be charged the full amount for the booked appointment and that I must give 48 hours notice for any cancellation or rescheduling of a booked appointment. If said notice is not given I acknowledge that a cancellation or rescheduling fee will be applied to the Credit Card number that I have provided at the time of initial booking, or will be charged to me upon my next visit.