• If yes, please provide their name and address:
  • If yes, please provide which company? (ex. Greenshield, Manulife etc.)
  • Please note: For direct billing, with many insurance companies a doctor’s note must be submitted prior to first treatment. We recommend contacting your insurance company prior to treatment to fully understand your plan.
  • If none, please indicate "None". If “yes,” please specify
  • If none, please indicate "N/A" or "None".
  • If none, please indicate "N/A" or "None".
  • If none, please indicate "N/A" or "None".
  • I hereby certify that I have read and understand all the questions relative to my health and medical history. I have completed all the information accurately and am aware of no health conditions not specifically mentioned in the case history. I will notify the massage therapist of any changes in my medical profile and agree that there shall be no liability on the therapist’s part should I fail to do so.
  • I understand the massage therapy session I receive is for relaxation, relief of muscular tension or pain, and improving circulation. If I experience discomfort, I will notify the massage therapist. I understand massage therapy is not a substitute for medical examination or treatment, that massage therapists do not diagnose, prescribe, or treat any illness, and that nothing in the course of the session(s) should be construed as such.
  • I hereby absolve Coral Medical Health Spa, and the attending massage therapist of all claims and responsibility for any unwanted effects to my health as a result or consequence of my massage therapy treatment.
  • If I no show or cancel within 24 hours of my appointment I agree to pay my massage therapists no show/last minute cancelation fee. This fee can be up to the full price of treatment. I understand that if I arrive late for an appointment, I am expected to pay for the full session and any extension beyond the originally scheduled ending time will be at the therapist’s discretion.
  • I understand that ANY type of sexual harassment/misconduct is absolutely forbidden. This is defined but not limited to the exposure of any body parts in the “bikini area” (unless I am doing a Brazilian/Bikini treatment), inappropriate touching, sexual innuendo’s, aggressive come-ons, comments about my providers physical appearance or comments which would make my provider fearful or uncomfortable. I also understand that failure to adhere to this policy will result in a lifelong ban from the facility.