Infinity Intake Form - Infinity Spa at Grand Colorado on Peak 8

Name*

First Last

Email*

Phone*

Date of Birth*

Are you pregnant?

How many weeks?

Medical Release for Prenatal Spa Treatments

Infinity Spa provides a variety of spa services, treatments, therapies and procedures. Certain Spa Treatments are not recommended for pregnant women during the first trimester of pregnancy, including massage therapy, body wraps, hot stone massage, reflexology and aromatherapy which are considered contraindicated services ("Treatments" used individually or collectively). If you are pregnant, it is suggested that you discuss receiving these services with your prenatal healthcare provider prior to receiving any such treatments.

I verify that I have discussed with my prenatal healthcare provider/physician any health concerns that I had about my participation in any Spa Treatments, including without limitation any contraindicated services listed above, and I understand and freely accept the potential risks of such Spa Treatments. I also understand that I am free to withdraw my consent and to discontinue participation in any Treatments at any time. Having read, discussed, and understood the above information, I further verify that I have obtained my prenatal healthcare provider's release and disclosed all high risk conditions of pregnancy. I do forever release the Spa, its therapists, practitioners, employees, agents, and each of their insurers, from all liability of any occur to of any nature whatsoever, whether past, present, or future for any injury or damage which may occur to myself or my family as a result of my participation in any Spa Treatments. I also agree to hold harmless and defend the Spa, its therapists, practitioners, employees and agents from all actions, claims, or other legal or administrative action that arises or may arise directly or indirectly out of my and my child's participation in any Spa Treatments.

Consent

I have read and accept the Prenatal Medical Release conditions

How did you hear about us?

Treatment Information

Have you had any of the following symptoms within the last 72 hours?

Fever/Chills
Shortness of Breath/Difficulty Breathing
Congestion or Runny Nose
Dry Cough
Sore Throat
Loss of Taste or Smell
Fatigue
Nausea
Rash: Open Wounds; Warts (Hands/Feet)

I will keep my face covered for the duration of the service and in indoor areas open to the general public whenever six feet of separation cannot be maintained.*

I agree

Please describe any skin conditions, allergies or sensitivities that you may have:

Do you have any medical conditions, previous/existing chronic injuries, accidents or surgeries that would interfere with today’s services?

Please list anything else that we need to know for your treatment:

Treatment Enhancements

Our staff is dedicated to providing a luxuriously tailored treatment for you. Please see our treatment enhancements. Please note these enhancements do not add additional time to your treatment.

Please indicate below if you would like to select any of our specialty enhancements ($20 for one or $30 for both):*

Eye Rejuvenating Mask
Lip Rejuvenating Mask
Both
None

Please indicate below if you would like to select any of our specialty enhancements ($20 for one or $30 for both):

Hydrating Hand Treatment
Hydrating Foot Treatment
Both
None

Please indicate below if you would like to select any of our CBD enhancements ($25 each or $35 for two):*

CBD Facial Treatment (added to facials only)
CBD Massage/Body Treatment
CBD Muscle Balm
CBD Spot Treatment (choose from 3 concentrates)
None

Infinity Spa Intake Form

Medical Release for Prenatal Spa Treatments

Treatment Information

Treatment Enhancements