Massage Intake Form

Please take a minute to fill in the following info

First Name*

Last Name*

Date of Birth*

Email*

Phone Number*

Occupation:*

Employer:

Primary Physician:

Emergency Contact:*

Emergency Contact Relationship:*

Emergency Contact Phone:*

How did you hear about us?

Medical Information

Are you taking any medications?*

If yes, please list name and use:

Are you currently pregnant?*

If yes, how far along:

Any high risk factors?

Do you suffer from chronic pain?*

If yes, please explain:

What makes it better?

What makes it worse?

Have you had any orthopedic injuries?*

If yes, please list:

Please indicate any of the following that apply to you:*

Cancer

Headaches/Migranes

Arthritis

Diabetes

Joint Replacement

High/Low Blood Pressure

Neurotherapy

Fibromyalgia

Stroke

Heart Attack

Kidney Dysfunction

Blood Clots

Numbness

Sprains or Strains

None of the above

Explain any conditions you have marked above:

Are there any other conditions that not listed above?

Have you had a professional massage before?

What pressure do you prefer?*

Do you have any allergies or sensitivities?*

If yes, please explain:

What are your goals for this treatment session?

By signing below, I agree that all the information above is true.*

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Renew Balance Massage & Wellness

Cold Plunge Participant Waiver and Release of Liability

*First name

*Last name

*Phone

*Date

Month

Day

Year

*Email

*Birthday

Month

Day

Year

Acknowledgment of Risks

I understand that participation in the cold plunge experience at Renew Balance Massage & Wellness involves exposure to cold water and carries inherent risks, including but not limited to:

Cold shock response
Increased heart rate and blood pressure
Hyperventilation
Dizziness or fainting
Muscle cramps
Slipping or falling
Hypothermia
Cardiac events
Serious injury or, in rare circumstances, death

I voluntarily choose to participate and fully accept all risks associated with this activit

Health Acknowledgment

I certify that I am physically able to participate in a cold plunge. I understand that I should not participate without prior approval from a qualified healthcare provider if I have, or suspect I have, conditions such as:

Heart disease or cardiovascular conditions
High or uncontrolled blood pressure
Respiratory disorders
Epilepsy or seizure disorders
Raynaud's syndrome
Pregnancy
Any other medical condition that may increase the risks of cold exposure, I agree to disclose.

Safety Agreement

I agree to:

Follow all instructions provided by staff or organizers.
Exit the cold plunge immediately if instructed to do so.
Leave the water immediately if I experience chest pain, severe dizziness, difficulty breathing, numbness, confusion, or any other concerning symptoms.
Avoid alcohol or recreational drugs before participating.

Release of Liability

To the fullest extent permitted by law, I release and hold harmless the organizer, facility owner, employees, contractors, volunteers, and affiliates from any and all claims, demands, damages, liabilities, costs, or expenses arising out of or related to my participation, including injuries resulting from ordinary negligence.

This release does not apply to conduct involving gross negligence, reckless misconduct, or intentional wrongdoing where prohibited by law.

Medical Treatment

If I require emergency medical care, I authorize the organizer to obtain appropriate treatment on my behalf if I am unable to do so. I understand that I am responsible for any medical expenses incurred.

Photo and Video Release (Optional)

I consent to photographs and videos being taken during the event and used for promotional or educational purposes.

I do not consent.

Facility Rules and Participant Responsibilities

To help maintain a safe, sanitary, and enjoyable environment for all participants, I agree to the following:

I will arrive with clean skin and will shower before entering the cold plunge whenever requested by staff.
I will not enter the cold plunge if I am wearing sunscreen, tanning lotion, body oils, self-tanning products, or other topical creams or lotions that may contaminate the water.
I will not enter the cold plunge if I have any open wounds, contagious illness, or skin condition that could pose a health risk to myself or others.
I will not enter the cold plunge if I am experiencing vomiting, diarrhea, or any condition that may result in contamination of the water.
I understand that urinating, spitting, vomiting, or releasing any other bodily fluids into the cold plunge is strictly prohibited.
I agree to use the facility in a clean, respectful, and sanitary manner and to follow all instructions provided by Renew Balance Massage & Wellness staff.
I understand that failure to follow these rules may result in immediate removal from the cold plunge area without a refund and may result in suspension or termination of future access to the facility.

Acknowledgment

I have read this waiver carefully, understand its contents, and sign it voluntarily. I acknowledge that I am giving up certain legal rights by signing this document.

Signature

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Massage Intake Form

Medical Information

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