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Please read fully and complete this page prior to your appointment at the Sugar Hut Express Spa

Full Legal Name*


Phone number*

Email Address*

Mailing Address*

Appointment Day*

TakeCare Member Number

Appointment Type (check all that apply)


Select an option

Problem Areas

History (Surgeries, Contraindications to Massage, Allergies to Coconut or Essential Oil, Other Information Therapists Should Be Aware of)*

DISCLAIMER & WAIVER. Because a Massage Therapist must be aware of any existing physical conditions that i may have, I have listed all my known medical conditions and physical limitations and I will inform my therapist of any changes in my physical health. I understand and agree that: (1) the massage therapy that I am given is for the purpose of stress reduction, relief for muscular tension or spasm and/or for improving blood circulation; (2) that a massage therapist neither diagnoses illness, disease or any other medical, physical or mental disease/condition, nor performs any spinal manipulations; (3) I am responsible for consulting a qualified physician for any physical ailments that I may have and prior determination of whether I am physically fit and in good medical condition to receive a massage. I AM FULLY AWARE OF THE RISKS INVOLVED AND HAZARDS CONNECTED WITH SKIN CARE TREATMENTS AND/OR MASSAGE THERAPY, AND I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE, OR PERSONAL INJURY THAT MAY BE SUSTAINED BY ME AS A RESULT OF THE ABOVE TREATMENT(S), OR ANY LOSS OR DAMAGE TO PROPERTY OWNED BY ME AS A RESULT OF BEING ENGAGED IN SUCH AN ACTIVITY AS THE ABOVE TREATMENT(S), WHETHER CAUSED BY NEGLIGENCE OR OTHERWISE. I HOLD THE SUGAR HUT EXPRESS SPA, ITS OFFICERS, STAFF, AND AGENTS HARMLESS AGAINST LIABILITY.*

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