Full Name

Room Number

Phone Number

Email Address

Contact Name

Contact Phone

Treatment(s) Received

Date of Treatment

Are you currently under medical care? Yes No

If yes, please specify

Do you have allergies? Yes No

If yes, please list

Are you pregnant? Yes No

Do you have any of the following conditions?

I confirm that the above information is correct and I consent to receiving spa treatments provided by the hotel.  I acknowledge that I have informed the therapist of all relevant health conditions.

Signature

Date